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Property of the

Lancaster City and County
Medical Society

THE

AMERICAN JOURNAL

OP THE

MEDICAL SCIENCES.

EDITED BY

ISAAC HAYS, M.D.,

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE
AMERICAN MEDICAL ASSOCIATION | OF THE AMERICAN PHILOSOPHICAL SOCIETY | OF THE
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; ASSOCIATE FELLOW
OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES,

&c. &c. &c.

NEW SERIES.

VOL. XXXIV.

PHILADELPHIA:
BLANCHARD & LEA.

1857.

69460

Entered according to the Act of Congress, in the year 1857, by
BLANC HARD AND LEA,

in the Office of the Clerk of the District Court of the United States in and for the
Eastern District of the State of Pennsylvania.

PHILADELPHIA:
T. K. AND P. G. COLLINS, PRINTERS.

A 513

^(9 READERS AND CORRESPONDENTS.

Communications have been received from Drs. Dalton, Coolidge, Hamilton,
McDowell, Earle, Curtis, Fleming, Finkham, and Wells, which shall receive
early attention.

The following works have been received : —

Lettsomian Lectures on Insanity. By Forbes Winslow, M. D., D. C. L., &c.
&c. London, 1854. (From the Author.)

On the Diseases, Injuries, and Malformations of the Rectum and Anus, with
Remarks on Habitual Constipation. By T. J. Ashton, Surgeon to Blenheim
Dispensary, F. R. C. S., &c. &c. Second edition. London, 1857. (From the
Author.)

Notes on Belgian Lunatic Asylums: including the Insane Colony of Gheel.
By John Webster, M. D., F. R.'S., &c. &c. (From the Author.)

Notices sur Hyeres et Cannes. Par Edwin Lee, M. D. Suivies d'observa-
tions sur l'influence du climat dans la Phthisie pulmonaire. Paris, 1857.
(From the Author.)

Principles of Medicine: An Elementary View of the Causes, Nature, Treat-
ment, Diagnosis, and Prognosis of Disease. With brief Remarks on Hygienics,
or the Preservation of Health. By Charles J. B. Williams, M. D., F. R. S»
A new American from the third Revised London Edition. Philadelphia:
Blanchard & Lea, 1857. (From the Publishers.)

On Diseases of the Skin. By Erasmus Wilson, F. R. S. Fourth American
from the fourth and enlarged London edition. Philadelphia: Blanchard &
Lea, 1857. (From the Publishers.)

On the Diseases of Women: Including those of Pregnancy and Childbed.
By Fleetwood Churchill, M. D., T. C. D., M. R. I. A., Vice-President of the
King's and Queen's College of Physicians in Ireland; One of the Presidents
of the Obstetrical Society, etc. etc. A new American edition revised by the
author. With notes and additions. By D. Francis Condie, M.D., Fellow of
the College of Physicians of Philadelphia, etc. etc. Philadelphia: Blanchard
& Lea, 1857. (From the Publishers.)

Manual of Physiology. By William Senhouse Kirkes, M. D., Fellow of
the Royal College of Physicians, etc. With two hundred illustrations. Phila-
delphia: Blanchard & Lea, 1857. (From the Publishers.)

A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice
of Medicine, Chemistry, Obstetrics, Materia Medica, Pharmacy, and Thera-
peutics. Especially designed for Students of Medicine. To which is added a
Medical Formulary. By J. L. Ludlow, A. M., M. D. A new edition, tho-
roughly revised and much enlarged. With three hundred and seventy illus-
trations. Philadelphia: Blanchard & Lea, 1857. (From the Publishers.)

Indigenous Races of the Earth: or, New Chapters of Ethnological Inquiry;
Including Monographs on Special Departments of Philology, Iconography,
Cranioscopy, Palaeontology, Pathology, Archaeology, Comparative Geography,
and Natural History. Contributed by Alfred Maury, Bibliothecaire de l'ln-
stitut de la France, etc.; Francis Pulszky, of Lubocz and Cselfalva, and J.
Aitken Meigs, M. D., Prof, of the Inst, of Med. in the Phil. Coll. of Med.
(With Communications from Prof. Jos. Leidy, M. D., and Prof. L. Agassiz,
LL. D.) Presenting Fresh Investigations, Documents, and Materials. By J.
C. Nott, M. D., Mobile, Ala. and Geo. R. Gliddon, Formerly U. S. Consul at
Cairo, Authors of Types of Mankind. Philadelphia: J. B. Lippincott & Co.
London: Trubner & Co., 1857. (From the Publishers.)

A Manual of the Detection of Poisons by Medico-Chemical Analysis. By
Dr. Fr. Jul. Otto, Professor of Chemistry in Caroline College, Brunswick.
Translated from the German, with Notes and Additions by William Elderhorst,
M. D., Prof, of Chem. in the Rensselaer Polytechnic Institute, Trov, N. Y.
New York : H. Baillure, 1857. (From the Publishers.)

The Transactions of the New York Academy of Medicine. Instituted 1847.
Vol. I., Part IX. ; Vol. II., Part I. Printed for the Academy. New York: S.
S. & W. Wood, 1857. (From Dr. Isaacs.)

TO READERS AND CORRESPONDENTS.

Transactions of the Medical Society of the State of New York. Transmit-
ted to the Legislature Feb. 9, 1857.

Smithsonian Contributions to Knowledge. Investigations, Chemical and
Physiological, relative to certain American Vertebrata. By Joseph Jones,
M. D., Professor of Chemistry in the Savannah Medical College. Washington
City : Published by the Smithsonian Institution, July, 1856. (From the Au-
thor.)

Catalogue of Human Crania, in the Collection of the Academy of Natural
Sciences of Philadelphia. Based upon the third edition of Dr. Morton's " Ca-
talogue of Skulls," &o. By J. Aitken Meigs, M. D., Librarian of the Academy
of Natural Sciences of Philadelphia, &c. Philadelphia: J. B. Lippincott &
Co., 1857.

The Transactions of the Academy of Science of St. Louis. (With Plates
Illustrating Papers.) St. Louis, 1857.

Constitution and By-Laws of the West Chester County (New York) Medical
Society, and the Proceedings of the Society at its Annual Meeting held in the
Village of Sing Sing, June 2, 1856. Sing Sing, 1857.

On Dysentery and its Treatment. By Henry Tiedemann, M. D., Member of
the College of Physicians, and of the Acad, of Nat. Sciences at Philadelphia.
Philadelphia, 1857. (From the Author.)

Fourteenth Annual Report of the Managers of the State Lunatic Asylum.
Transmitted to the Legislature Jan. 7, 1857. Albany, 1857.

Seventieth Annual Report of the Regents of the University of the State of
New York. Transmitted to the Legislature Jan. 22, 1857. Albany, 1857.

Fortieth Annual Report of the State of the Asylum for the Relief of Per-
sons deprived of the use of their Reason. Published by direction of the Con-
tributors, third month, 1857. Philadelphia, 1857.

Annual Report of the Physician in Chief of the Marine Hospital at Quaran-
tine. Presented to the Legislature Feb. 4, 1857. Albany, 1857. (From Dr.
E. Harris.)

Fourteenth Annual Report relating to the registry and return of Births, Mar-
riages, and Deaths in Massachusetts for the year 1855. Boston, 1857. (From
Dr. Edward Jarvis.)

Twenty-fourth Annual Report of the Trustees of the State Lunatic Hospital
at Worcester, Dec. 1856. Boston, 1858. (From Dr. Edward Jarvis.)

Eighth Annual Report of the Massachusetts School for Idiotic and Feeble-
minded Youth. Cambridge, 1856. (From Dr. Edward Jarvis.)

Report of the Board of Trustees of the Massachusetts General Hospital pre-
sented to the corporation at their annual meeting Jan. 28, 1857. Boston, 1857.
(From Dr. Edward Jarvis.)

Fourth Annual Report to the General Assembly of Kentucky relating to the
Registry and Returns of Births, Marriages, and Deaths, in the State of Ken-
tucky, from January 1 to December 1, 1855.

An Inaugural Thesis on Intra-Capsular Fractures of the Cervix Femoris.
By John Geo. Johnson, of Mass. (Reprinted from New York Journ. Med.,
May, 1857.) New York, 1857. (From the Author.)

First Anniversary of the Woman's Hospital, held at Clinton Hall, Astor
Place, New York, Feb. 9, 1856. New York, 1856.

Constitution and Second Annual Report of the Woman's Hospital Associa-
tion. Presented by the Board of Managers at the Anniversary Meeting, Jan.
12, 1857. New York, 1857.

Memorial to the Honourable the Legislature of the State of New York, for
founding a Woman's Hospital, 1857. New York, 1857.

An Act to Found a Woman's Hospital for the State of New York, passed
April 8, 1857. New York, 1857.

Professor Mitchell's Charge to the Graduates of the Jefferson Medical Col-
lege of Philadelphia, Ma^ch 7, 1857. With a list of Graduates. (From the
Author.)

Valedictory Address to the Class of Graduates of the Missouri Medical Col-
lege at the Annual Commencement of the Session of 1856-57. By E. S. Fra-
zer, M. D., Prof, of Obstetrics and Diseases of Women and Children. St. Louis,
Mo., 1857.

TO READERS AND CORRESPONDENTS.

An Introductory Lecture on Medicinal Education delivered at the Philadel-
phia College of Medicine March 9, 1857. By Henry Hartshorne, M. D., Prof,
of Theory and Pract. Med. (Published by the Faculty.) Philadelphia, 1857.

The Physicians of the Last Century, A Lecture introductory to the Course
at the Philad. Assoc. for Med. Instruction, March 23, 1857. By J. Da Costa,
M. D., Lect. on Prin. and Pract. Med. Published by the Class. Philadelphia,
1857. (From the Author.)

Knowledge of the only Guide to Action. An Address to the Graduates of
the St. Louis Medical College. Delivered Feb. 28, 1857. By Prof. J. H. Wal-
ters, M. D. (Published by request of the Class.)

Eulogy on Samuel McClellan, M. D. Prepared by order of the Medical So-
ciety of the State of New York, and read at the Annual Meeting in Albany,
Feb. 3, 1857. By Thomas W. Blatchford M. D. Albany, 1857.

Semi-Centennial Address. Delivered before the Medical Society of the State
of New York and Members of the Legislature in the Capitol at Albany Feb.
4, 1857. By Alden March, M. D., President of the Society. Albany, 1857.

Catalogue of the Officers and Students in the Cleveland Medical College.
Session of 1856-57. Cleveland, 1857.

Savannah Medical College. Circular and Catalogue of the Trustees, Faculty,
and Students. Announcement of Lectures, Session 1857-58. Savannah, 1857.

Catalogue of the Medical College of Virginia. Session 1856-57. Richmond,

Catalogue Raisonne of the Medical Library of the Pennsylvania Hospital.
By Emil Fischer, M. D. Printed by order of the Board of Managers. Phila-
delphia: Printed by T. K. & P. G. Collins, 1857. (Advance Copy from the
Hospital.)

The following Journals have been received in exchange : —

Moniteur des Hopitaux. Redacteur en chef, M. H. De Castelnau. March,
April, May, 1857.

L'Art Dentaire. Par MM. Fowler et Preterre. January, February, March,
April, 1857.

Medical Times and Gazette. April, May, June, 1857.

Edinburgh Medical Journal. March, April, May, 1857.

British Medical Journal, being the Journal of the British Medical Associa-
tion. Edited by Andrew Winter, M. D. March, April, May, 1857.

The Dublin Hospital Gazette. March, April, May, 1857.

The British and Foreign Medico-Chirurgical Review. April, 1857.

The Journal of Psychological Medicine and Mental Pathology. Edited by
Forbes Winslow, M. D. April, 1857.

The Dublin Quarterly Journal of Medical Science. May, 1857.

The Indian Annals of Medical Science. October, 1856.

The Sanitary Review and Journal of Public Health, including Transactions
of the Epidemiological Society of London. Edited bv B. W. Richardson, M. D.
March, 1857.

The Glasgow Medical Journal. April, 1857.

The Medical Chronicle, or Montreal Monthly Journal of Medicine and Sur-
gery. Edited by Drs. Wright and McCallum. February, March, April, May,
June, 1857.

The Virginia Medical Journal. Edited by Drs. McCaw and Otis. April,
May, June, 1857.

The Peninsular Journal of Medicine. Edited by Z. Pitcher, M. D. and A.
B. Palmer, M. D. April, May, June, 1857.

The Southern Journal of the Medical and Physical Sciences. Edited by
Richard 0. Currey, M. D., &c. April, May, June, 1857.

The American Journal of Dental Science. Edited by Chapin A. Harris,
M.D., D. D. S., and A. Snowden Piggott, M. D. April, 1857.

The Western Lancet. Edited by Geo. C. Blackman, M. D. April, May, 1857.

The Medical and Surgical Reporter. Edited by S. W. Butler, M. D. April,
June, 1857.

TO READERS AND CORRESPONDENTS.

Atlanta Medical and Surgical Journal. Edited by Jos. P. Logan, M.D. and
W. F. Westmorland, M. D. April, May, 1857.

American Journal of Science and the Arts. Conducted by Profs. B. Silli-
man, B. Silliman, Jr., and J. D. Dana. May, 1857.

The Medical Independent. Edited by E. Kane, M. D. and L. G. Robinson,
M. D. April, 1857.

Southern Medical and Surgical Journal. Edited by Henry F. Campbell,
M. D., and Robert Campbell, M. D. April, May, June, 1857.

The American Journal of Insanity. Edited by the Medical Officers of the
New York State Lunatic Asylum. April, 1857.

The New York Journal of Medicine. Edited by S. S. Purple. M. D.,
Stephen Smith, M. D., and H. D. Bulkley, M.D. January, May, 1857.

The American Journal of Pharmacy. Edited by Wm. Proctor, M. D. May,

The Buffalo Medical Journal. Edited by Sanford B. Hunt, M. D. April,
May, 1857.

Iowa Medical Journal. Conducted by the Faculty of the College of Physi-
cians and Surgeons of the Iowa University. November and December, 1856.

The North American Medico-Chirurgical Review. Edited by S. D. Gross,
M. D., and T. G. Richardson, M. D. May, 1857.

The Ohio Medical and Surgical Journal. Edited bv John Dawson, M. D.
May, 1857.

Charleston Medical Journal and Review. Edited by C. Happoldt. Mav,
1857.

New Orleans Medical News and Hospital Gazette. Edited by Drs. Chappin,
Beard, and Brickell. May, June, 1857.

The New Orleans Medical and Surgical Journal. Edited by Bennet Dow-
ler, M. D. May, 1857.

Memphis Medical Recorder. Edited by A. P. Merrill, M. D. May, 1857.

The American Medical Gazette. Edited by D. Meredith Reese, M. D., &c.
April, May, June, 1857.

Nashville Journal of Medicine and Surgery. Edited by W. K. Bowling, M.
D., assisted by Paul F. Eve, M. D. April, May, June, 1857.

St. Louis Medical and Surgical Journal. Edited by M. L. Linton, M. D.,
and W. M. McPheeters, M. D. March, May, 1857.

The Cincinnati Medical Observer. Edited by Drs. Mendenhall, Murphey,
and Stevens. April, May, June, 1857.

The North-Western Medical and Surgical Journal. Edited by N. S. Davis,
M. D. March, May, 1857.

The California State Medical Journal for Jan. 1857. Edited by J. F. Morse,
M.D.

The New Hampshire Journal of Medicine. Edited by Geo. H. Hubbard,
M. D. April, May, 1857.

The Monthly Stethoscope. Edited by G. A. Wilson, M. D., and R. A. Lewis,
M. D. April, May, 1857.

Communications intended for publication, and Books for Review, should be sent, free
of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the Me-
dical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed as
above, and (carriage paid) under cover, to John Miller, Henrietta Street, Covent Gar-
den, London; or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will reach lis
safely and without delay. We particularly request the attention of our foreign corre-
spondents to the above, as we are often subjected to unnecessary expense for postage
and carriage.

Private communications may be addressed to the Editor, at his residence, 1525
Locust St.

All remittances op money, and letters on the business of the Journal, should be
addressed exclusively to the publishers, Messrs. Blanchard & Lea.

Jg^° The advertisement-sheet belongs to the business department of the Journal,
and all communications for it should be made to the publishers.

CONTENTS

or THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

NO. LXVII. NEW SEEIES.
JULY, 1857.

ORIGINAL COMMUNICATIONS.

MEMOIRS AND CASES.

ART. PAGE

I. Phenomena of the Capillary Circulation. By Austin Flint, Jr., M. D. - 13

II. On the Treatment of Scarlatina by the Diluted Acetic Acid. By B. F.
Schneck, M. D., of Lebanon, Pa. ------ - - 27

III. Cases of Partio-General Paralysis, or the Paralysis of the Insane. By
Pliny Earle, M.D. - - - 36

IV. Reports of Cases treated in the Pennsylvania Hospital. By John H.
Packard, M. D., late Resident Physician at the Pennsylvania Hospital. - 51

V. Statistics of Obstetrical Cases. By Daniel Pierson, M. D., Augusta, 111.
(Prepared for, and read before the Hancock Co. (111.) Medical Associa-
tion, and communicated to the Am. Journ. Med. Sci. for publication, in
compliance with a vote of the Society.) -------56

YI. Chlorate of Potash in Mercurial Stomatitis. By Thomas J. Gallaher,
M. D., one of the Physicians to the Western Pennsylvania Hospital,
Pittsburg. 64

VII. Chlorate of Potash Injections in Leucorrhoea and Ulceration of the
Os Uteri. By Bedford Brown, M. D., Caswell County, N. C. - - - 66

YIII. The Use of Water in the Treatment of Fever. By Isaac Casselberry,
M. D., Evansville, Ind. 68

IX. Does Pregnancy accelerate or retard the Development of Tubercles of
the Lungs in persons predisposed to this Disease ? By Edward Warren,
M. D., of Edenton, North Carolina. The Dissertation to which the Fiske
Fund Prize was awarded, June 4, 1856. (Published by request of the
Rhode Island Medical Society.) 87

REVIEWS.

X. Statistical Report on the Sickness and Mortality in the Army of the
United States, compiled from the Records in the Surgeon-General's Office ;
embracing a period of Sixteen Years, from 1839 to 1855. Prepared under
the direction of Brevet-Brigadier-General Thomas Lawson, Surg. Gen.
U. S. Army, by Richard H. Coolidge, M. D., Assistant Surgeon U. S.
Army. Washington, 1856. - 119

CONTENTS.

ART. PAGE

XL Traite Therapeutique du Quinquina et de ses Preparations. Par P.
Briquet, Medecin a THopital de La Charite, &c. &c. Deuxieme edition.
Paris, 1855.

Therapeutical Treatise on Cinchona and its Preparations. By P. Briquet,
Physician of La Charite, &c. &c. Second edition, Paris, 1855. - - 142

XII. Traite de Chimie Anatomique et Physiologique, Normale et Patholo-
gique, ou des Principes Imraediats Normaux et Morbides qui constituent
le Corps de l'Homme et des Mammif eres. Par Charles Robin et F. Ver-
deil. 3 volumes, et Atlas de 45 Planches. Paris, 1855.

Treatise on Anatomical and Physiological Chemistry, Normal and Patholo-
gical ; or of the Immediate Principles, Normal and Morbid, which con-
stitute the Body of Man and of the Mainmiferse. By Charles Robin and
F. Verdeil. 3 vols., and an Atlas of 45 Plates. Paris, 1853. - - 158

BIBLIOGRAPHICAL NOTICES.

XIII. A Claim of Priority on the Discovery of, and also the Naming of the
Excito-Secretory System of Nerves. By Henry Fraser Campbell, M. D.,
of Augusta, Georgia, U. S. A., Member of the American Medical Asso-
ciation, etc. etc. 8vo. pp. 16. 177

XIV. Reports of American Institutions for the Insane.

1. Of the, New Jersey State Asylum, for the year 1856.

2. Of the Pennsylvania Hospital for the Insane, for 1856.

3. Of the Pennsylvania State Hospital, for 1856.

4. Of the Western Pennsylvania Hospital, for 1856.

5. Of the Mount Hope Institution, for 1856.

6. Of the North Carolina State Asylum, for 1856.

7. Of the South Carolina State Asylum, for 1856.

8. Of the Indiana State Hospital, for 1856.

9. Of the Illinois State Hospital, for 1856.
10. Of the Missouri State Asylum, for 1856.

11. Of the California State Asylum, for 1855. 180

XY. On Dysentery and its Treatment. By Henry Tiedemann, M. D., Mem-
ber of the College of Phvsicians, and of the Academy of Natural Sciences
at Philadelphia. 12mor pp. 29. Philadelphia, 1857. - - - - 192

XVI. Clinical Lectures on Certain Diseases of the Urinary Organs, and on
Dropsies. By Robert Bentley Todd, M. D., F. R. S., Physician to King's
College Hospital. 8vo. pp. 283. Philadelphia: Blanchard & Lea, 1857. 197

XVII. On the Diseases of Women, including those of Pregnancy and Child-
bed. By Fleetwood Churchill, M. D., T. C. D., M. R. I. A., etc. etc. A
new American edition, revised by the Author. With notes and addi-
tions by D. Francis Condie, M. D., etc. etc. 8vo. pp. 768. Philadel-

phia: Blanchard & Lea, 1857. 198

XVIII. Manual of Physiology. By William Senhouse Kirkes, M. D., etc.
etc. A new and revised American, from the last London edition. With
two hundred illustrations. 12mo. pp. 584. Philadelphia: Blanchard

& Lea, 1857. - 201

XIX. A Manual of the Detection of Poisons by Medico-Chemical Analysis.
By Dr. Fr. Jul. Otto, Professor of Chemistry in Caroline College, Bruns-
wick. Translated from the German by Wm. Elderhorsz, M. D., Profes-
sor of Chemistry in the Rensselaer Polytechnic Institute, Troy, N. Y.
12mo. pp. 178. New York, 1857. 201

CONTENTS.

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.

FOREIGN INTELLIGENCE.
Anatomy and Physiology.

page

1. On the Physiological Mechanism
of the Formation of Sugar in the
Liver. By CI. Bernard. - - 203

2. Researches relative to the Influ-
ence of Alkalies and Alkaline
Carbonates in Destroying Glu-
cose. By M. Jeannel. - - 205

3. On a but little known Function
of the Pancreas, the Digestion
of Azotized Food. By M. L.
Corvisart. 206

4. Digestion and Absorption of
Fatty Substances without the
Concurrence of the Pancreatic
Juice. By M. Colin. - - 206

page

5. Alcoholic Fermentation. By

M. Berthelot. - - - - 207

6. On the Mode of Action of the
Gastric Juice. By Dr. Blondlot. 207

7. Quantity of Air inspired at
every 5, 15, and 30 minutes of
the Day and Night, and under
the Influence of Exercise, Food,,
and Medicines — on the Tempe-
rature of the Body, &c. By Ed-
ward Smith. - - - - 208

8. Complete Obliteration of the
Thoracic Aorta. By Mr. Sid-
ney Jones. .... 211

Materia Medica and Pharmacy.

9. Experiments on the Action of
Pepsin. By Edward H. Sieve-
king. - - - - ^ - 212

10. Chemical and Physiological
Properties of Pepsin. By M.
Boudault. 214

11. Therapeutic Employment of
the Pvrophosphate of Iron. By

M. E.'Robiquet. - - - 215

12. Therapeutic Properties of Io-
dide of Potassium. By MM.
Demarquay and Gustin. - - 217

13. Employment of Amylene for
Children. By M. Giraldes. - 217

14. External Use of Clay. By Dr.
Betz. ..... 217

Medical Pathology and Therai

15. On the Diseases of the Army
of the East during the winter of
1854-5. By Dr. Tholozan. - 217

16. On the Identity of the Specific
Causes of Typhus and Typhoid
Fever. By Dr. Gibbon. - - 220

17. Analysis of Fifty-two Cases of
Epilepsy. By Dr. Sieveking. - 222

18. On the Curable Stage of Phthi-
sis. By Dr. Edward Smith. - 224

19. Diagnosis of Apneumatosis
(Pulmonary Collapse). By Dr.
Graily Hewitt. - 226

eutics, and Practical Medicine.

20. Rupture of the Heart. By Dr.
O'Ferrall. - - - < - - 227

21. Diabetes and Saccharine Con-
ditions of the Urine. By Dr. A.

B. Garrod. - - - - 229

22. On the Prevention of Consti-
pation. By Prof. Phoebus. - 230

23. Lactic Acid a Remedy for Dys-
pepsia. By Dr. Nelson. - - 231

24. Creasote in Erysipelas. By

Dr. Delarue. - - - - 232

25. Iodide of Ammonium. By Dr.

B. W. Richardson. - - - 232

CONTENTS.

PAGE

26. Liquor Sodae Chlorinatse as a
Local Application in Smallpox.

By Mr. John Gabb. - - -232

27. Fumigations of Essence of
Turpentine in Itch. By Dr. A.
Anselmier. - 232

28. Progressive Fatty Degenera-

tion and Atrophy of the Volun-
tary Muscles. By Mr. Leggatt. 232

29. On the Pathology of the Arti-
cular Cartilages. By Thomas
Bryant, Esq. .... 234

30. Unusual and Obstinate Form
of Swelling. By Mr. J. L. Mil-
ton. 235

Surgical Pathology and Therapeutics, and Operative Surgery.

31. Concussion of the Spinal Cord.

By Dr. J. S. Hughes. _ - - 237

32. The Constitutional Origin and
Treatment of Cancer. By Mr.
Weeden Cooke. - _ - - 240

33. Necrosis of Cancer and its Con-
sequent Enucleation. By M.
Moullin. - - . - - 241

34. Subclavian Aneurism Cured
by Displacing a Portion of its
Fibrinous Contents. By Mr.
Robert Little. - - - - 244

35. Ligature of Arteries in Suppu-
rating Wounds. ByM.Nelaton. 246

36. Forcible Extension and Rup-
ture of the Uniting Medium of
Partially Anchylosed Surfaces.

By Mr. Brodhurst. - - - 246

37. Excision of the Head of the
Femur and Floor of the Aceta-
bulum for Caries combined with
Febrile Abscess. By Mr. Henry
Hancock. 248

38. Treatment of Certain Diseases
of the Knee-joint by the Ope-
ration of Resection. By Mr.
Price. 249

39. Bony Union after Fracture of
the Cervix Femoris within the
Capsule. By T. Bryant, Esq. - 252

40. Ununited Fracture Remedied
by Operation. By James Syme,
Esq. - 252

41. Case of Mvopathic Luxation.

By Dr. Friedberg. - - - 253

42. Inflammation and Rupture of
the Rectus Abdominis. By Vir-
chow. 255

43. New Method of Operating for
Impermeable Urethra. By Mr.
Syme. 255

44. Excision of an Enlarged Third
Lobe of the Prostate in a Litho-
tomy Operation. - 257

45. Vesico- Vaginal Fistula. By

Dr. Jas. H. Sawyer. - - - 258

46. Valvular Nature of Strangu-
lated Hernia. By Prof. Roser. 260

47. Herniotomy in an Infant seven
weeks old. By Mr. Win. Ray-

48. Ovarian Dropsy treated by Io-
dine Injection. By Dr. J. B.
Brown. 261

Ophthalmology.

49. On the Employment of the
Ophthalmoscope in the Investi-
gation of Deep-seated Disease of
the Eye. By Holmes Coote. - 261

50. Sympathetic Inflammation of
the Globe. By Dr. R. Bell. - 263

51. Loss of Vision following the
Blow of a Whip; Recovery. - 265

52. The Relation of Cataract to
Heart Disease. By Mr. T. F.
Jordan. 266

53. Ought both Eyes, when Cata-
ractous and equally affected, to
be Operated on at the same
time? By Dr. John Sloan. -267

Midwifery.

54. Puerperal Fever. By Prof.
Murphy. - - - - " - 269

55. Saccharine Urine in Nursing
Women. - - - * ,.- - 271

56. Iodine in Vomiting in Preg-
nancy. By Dr. J. B. Schmitt. 272

57. Sterility. By Dr. Carl Mayer. 272

58. Involuntary Production of the
Lacteal Secretion by Electricity.

By Dr. A. Auber. - - - 273

59. Pregnancy in a Two-homed
Uterus. By Dr. Lumpe. - - 273

CONTENTS.

Medical Jurisprudence and Toxicology.

page

60. Death from the Inhalation of
Chloroform. By Jos. Allen, Jr.,
Esq. 273

61. Death from Amylene. By Dr.
John Snow. .... 375

62. Poisoning from the Applica-
tion of the Belladonna Plaster
to the Skin. By Dr. Wm. Jen-
ner. - - - - - - 278

PAGE

63. A New Poison. By M. De
Luca. 279

64. Alleged Mental Unsoundness
associated with Old Age. - 280

65. Transformation of Amygdaline
into Hydrocyanic Acid within
the Body. By Prof. Kolliker
and Dr. Miiller. - - - 282

Miscellaneous.

66. Ophthalmological Congress. --------- 282

AMERICAN INTELLIGENCE.
Original Communications.

Note of the Delivery of a Female,
one of whose Lower Limbs had
been Disarticulated at the Hip-
Joint, by Dr. Duffie, seventeen
years since, for Morbus Coxa-
rius. By John H.Packard, M.D. 283

Case of Fracture of the Pelvis dur-
ing Pregnancy. By J. Whita-
ker, M.D. 283

Ovariotomy Successful. By E. P.
Bennett, M. D. - - - - 284

Death following the Inhalation of

a Mixture of Ether and Chloro-.
form. By R. Crockett, M. D. - 284

Mental Influence of Mother on
Foetus in Utero exerted through
two successive Pregnancies. By
S. L. Kerr, M. D. - - - 285

Case of Arrest of Development.
By S. L. Kerr, M. D. - - 286

Case of Fibrinous Plugs in the Ab-
dominal Aorta, Right Iliac, and
Right Subclavian Arteries. By
G. A. Wilbur, M.D. - 286

Domestic Summary.

Excision of the Tonsils. By Dr.
J. Mason Warren. - - - 287

Complete Dislocation of the Cervi-
cal Vertebras. By Dr. Daniel
Ayres. 289

Femoral Aneurism Cured by Ve-
ratrum Viride, Manipulation
and Compression. By Dr. Geo.
C, Blackman. - - - - 290

Paracentesis Thoracis. By Dr.
Henry J. Bowditch. - - -291

Chalk and Vinegar in Intermittent
Fever. By Dr. Hodsden. - - 292

Gunshot Wound of the Heart and
Stomach. By Dr. J. H. Grant. 292

Dislocation of the Femur reduced
by Reid's Method. By Dr. T.
G. McElbright. - - - 292

Wutzer's Operation for the Radical
Reduction of Hernia. By Prof.
Geo. A. Blackman. - - - 292

Spina Bifida, with Malformation
of the Genitals. By Dr. S. Knee-
land, Jr. - - - - - 292

Treatment of Erysipelas with To-
bacco. By J. G. Stephenson. - 292

. . .#

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR JULY 1 8 5 7.

Art. I. — Phenomena of the Capillary Circulation.
By Austin Flint, Jr., M. D.1

The statements which I shall make from my own observation concerning
the capillary circulation, are based upon examinations made from time to time
during the past summer, nine of which have been carefully recorded. The
recorded observations were made on the web of the frog, although I have
made examinations of the various other parts where the circulation can be
conveniently exhibited, to which I shall refer.

The microscope used was the large instrument of Nachet, and, unless other-
wise stated, with a magnifying power of 165 diameters.

I shall first point out what I have found to be the most convenient methods
of conducting examinations of the circulation in the frog, and then proceed
to describe the various phenomena of the circulation as viewed by means of
the microscope, and then draw my deductions from these observations.

The parts of the frog which I have subjected to examination, are the web
of the foot, the tongue, the peritoneum, and the lungs. All parts but the
peritoneum require to be examined by transmitted light, but, in examining
the circulation in the latter situation, we are compelled to use reflected light.

It is exceedingly inconvenient to make observations while the frog has the
power of motion, and in securing it to the frog-plate in a proper position, we
are apt to interrupt or modify the circulation by constricting the vessels with
the bands which we must use. Under these circumstances, we are not able
to apply medicated solutions conveniently to the entire surface, and mechanical
or chemical irritation of any part occasions struggles which greatly increase

1 An Inaugural Dissertation laid before the faculty of Jefferson Medical College in
February, 1857.

No. XLYII. — July 1857. 2

Flint, Phenomena of the Capillary Circulation.

the difficulty of the experiment. By breaking up the medulla oblongata, or
even the posterior part of the brain (for it is not easy to invariably reach the
medulla without some practice), we are enabled to observe all the phenomena
of the circulation with great facility, avoiding the necessity of forcibly retain-
ing the frog in the desired position, with the consequent liability to constric-
tion of the vessels and shifting of the field of observation. I shall hereafter
refer to experiments of E. Brown Sequard, M. D., of Paris, and two of my
recorded examinations, which show that observations of the circulation may
be made with as much accuracy on a frog after the medulla has been destroyed,
as though it had not been subjected to the operation. The operation may be
performed by introducing a dissecting needle into the cranium, a line or two
behind the eyes, passing it backwards and a little downwards to the articula-
tion of the spine with the skull, and then thoroughly breaking up the medulla.
The web of the foot maybe examined in the following manner: "We first
break up the medulla oblongata in the manner just described, the frog will
then remain perfectly motionless in any position. The web may be stretched
over the opening in the frog-plate, and secured in position by means of pins ;
care being taken not to extend the web too forcibly, and to put no pins above
the foot, but nearly at the extremities of the toes, as in either case the circu-
lation may be disturbed. The part should then be moistened, and the lenses
of the microscope protected from the evaporation by a glass cover, broken to
fit between the toes.

The entire surface of the frog should be moistened from time to time with
cool water.

The magnifying power best adapted to such observations, is one of from
150 to 200 diameters.

In examining the tongue, we draw it out of the mouth, and stretch it so as
to form a thin transparent film, by means of the forceps and pins. The cir-
culation may be exhibited in the peritoneum by merely exposing that mem-
brane and examining it, with a power of 60 or 70 diameters, by reflected light.
The process of exhibiting the circulation in the lungs of the frog is much
more complicated and difficult than either of the preceding experiments, but
when successfully performed, it is one of the most beautiful and curious
demonstrations in the whole range of microscopic science.

Dr. Kobert Willis, in his edition of Wagner's Physiology, refers to the
appearances of the pulmonary circulation in the water newt. He directs that
the newt be strangled after an inspiration. " The abdomen is then to be laid
open, arjd the entire animal, being held in the hands, is placed upon a glass
plate a porte-objet, and one of the lungs brought into the field of view."
He observes, however, that the circulation lasts but a short time. The frog
appears to me to be a much better subject for this experiment, and as I have
never seen the process of showing the pulmonary circulation in this animal
detailed in the books, I shall describe it with some minuteness as practised by
Prof. John C. Dalton, of New York, and as repeated frequently by myself.

1857.] Flint, Phenomena of the Capillary Circulation. 15

In undertaking it, a large sized frog should be selected. After Laving
broken up the medulla oblongata, a ligature is to be placed around the larynx
in the following manner: The mouth being widely opened, the larynx is seen
just in front of the oesophagus. A ligature is now carried just under the
mucous membrane by means of a small curved needle. This is effected by
making four or five stitches, the needle being introduced at the point where
it came out at each preceding stitch, so that the ligature shall smoothly
encircle the larynx, and its extremities emerge at the same point. This being
done, a small blowpipe is introduced into the windpipe, and the ligature held
in readiness to be drawn tight by an assistant when required. The lungs
must now be moderately distended and the ligature tightened, at the same
time removing the blowpipe. If the side be now carefully opened the lung
will protrude, and may be examined by transmitted light.

It is very much more difficult to exhibit the circulation in the lungs than
in any other part. The chief difficulties to be encountered are the following :
First, it is no easy matter to fix the ligature properly around the larynx; but
when we have done this, if we distend the lungs too forcibly, they will either
burst or the circulation will be greatly impeded ; and if we do not distend
them sufficiently, they will not protrude when the side is opened. There is
also always some difficulty in introducing the blowpipe, and its delicate orifice
is often occluded by the secretion of the part. When we succeed, however,
in exhibiting the circulation in the lungs, the capillaries are seen encircling
the air-cells, which are quite large in the frog. This is an extremely beautiful
and interesting sight— but more as a scientific curiosity than as a field for
useful investigation. It was observed by Dr. Willis, and confirmed by Wag-
ner and Glluge, that the transparent plasma which we find occupying the space
next to the walls of the capillaries, in most situations, while the blood-disks
occupy the centre, constituting the still layer of Kirkes, is not observed
in the capillaries of the lungs ; in other words, the vessels are crowded to
their very walls with corpuscles.

For this remarkable deviation from a general law they offer no explanation.

I have never observed this peculiarity, as my attention was not directed to
it when examining the pulmonary circulation. Those who believe the heart
is solely instrumental in propelling the blood through the capillaries would
not be able to account for this phenomenon; but it seems to me it can be
explained in the following manner: The blood circulating in the systemic
capillaries nourishes the tissues by the liquor sanguinis, and thus the attract-
ive vital force operates on this constituent. The plasma then is nearest the
tissues and next the walls of the vessels ; but the pulmonary capillaries are
for the aeration of the blood, a process which is effected by the globules and
not by the plasma — since the great mass of blood is not sent to the lungs for
purposes of nutrition, but for aeration ; hence, the globules, which here feel
the force of attraction for oxygen, occupy tho space next the walls of the ves-
sels.

16 Flint, Phenomena of the Capillary Circulation. [July

Taking the view which I do of the causes of the capillary circulation, this
explanation is satisfactory.

Before proceeding to describe minutely the phenomena of the capillary cir-
culation, we will briefly consider the anatomical structure of the capillaries
and of the blood.

M. Robin recognizes three varieties of capillaries. The first variety is
from *° 8 3 0 °f an mcn m diameter, and is composed of a transparent
homogeneous membrane, 2 5V 0 °f an mcn m thickness, with nuclei, and some-
times nucleoli, projecting into the calibre of the vessel. The nuclei are
oval, with their longest diameter in the direction of the vessel. These are
embraced under the head of the " true capillaries" of Prof. Kolliker.

The second variety, M. Robin describes as having two coats : the membrane
with the longitudinal nuclei of the first variety, and, investing it, a second
membrane with transverse nuclei. The diameter of the second variety varies
from to 3-^5 of an inch. This variety also probably comes under the
head of the "true capillaries" as described by Kolliker, though he does not
mention the second investing membrane.

The third variety, M. Robin calls venules and arterioles, Kolliker, venous
and arterial transitionary vessels. Their diameter is from ^\ to of an inch,
and they have added to the two coats of the second variety a third coat of
areolar tissue. It seems to me most convenient and proper to consider the
first two varieties of M. Robin, or the " true capillaries" of Prof. Kolliker,
simply as capillaries (their tunic being a prolongation of the inner coat of the
arteries), and the third variety of M. Robin as venules and arterioles. We
may easily distinguish the arterioles from the venules, by noticing that the
arterioles give off branches, while the venules receive them; that the arterioles
diminish in size as we follow them in the direction of the current of blood,
while the venules increase in size.

The blood consists of a transparent plasma holding two kinds of corpuscles
in suspension, called the red and the white, or colorless. In the human sub-
ject the red corpuscles are disks like pieces of coin, but thinner in the centre
than at the edges. They have no nuclei, though the difference in thickness
causes the centre to appear dark when the edges are in focus. They are 3
of an inch in diameter. The white corpuscles are larger than the red, being
of an inch in diameter; they are globular, white, and granular. If
water be applied to them they are rendered transparent, and we can distinguish
a nucleus. They are much less numerous than the red corpuscles. In the
frog, the red corpuscles are oval and large, with a central rounded nucleus.
They are q of an inch in their long diameter. The white globules are
smaller and proportionally more numerous than in man. The blood-disks in
nearly all animals are red by reflected light, but of a pale amber colour by
transmitted light.

Having given an abstract of the anatomy of the capillaries and of the blood,
we are prepared to consider the phenomena of the circulation in these vessels.

1857.]

Flint, Phenomena of the Capillary Circulation.

In a paper communicated to the Medical Examiner, August, 1852, by E.
Brown Sequard, M. D., of Paris, entitled " Experimental Kesearches applied
to Physiology and Pathology," I find some very interesting observations on
the effect, or more properly the absence of effect, on the capillary circulation,
of the section of various nerves. This observer, with the assistance of Dr.
Siebert, found, " after the section of all the nerves (the sympathetic and
cerebro-spinal) in the legs of a number of frogs, that there was no appearance
of trouble in the capillary circulation, either in one hour or three or four days
after the division of the nerves." He concludes, from another experiment,
that the nervous action (that of the sympathetic as well as the cerebro-spinal
nerves) is not necessary for the change of colour of the blood in the capillaries.
It is proved, by this experiment, that the capillary circulation is not immedi-
ately dependent, in any measure, on nervous influence.

A curious fact has been observed by Bernard, viz : that, after a section of
the sympathetic in the neck, the corresponding side of the face, and more par-
ticularly the ear, becomes warmer and more sensitive than the other side.
The bloodvessels appear more numerous than before, and are enlarged. Brown
Sequard has repeated this experiment, and concludes that the increase of tem-
perature and sensibility is due merely to passive dilatation of the vessels from
paralysis of their coats and consequent congestion. I have myself seen the
experiment performed by Prof. Dalton, of New York, and concur with him
in the opinion that the increase in temperature and sensibility is rather due
to an exaggeration of the nutrition of the parts : for specimens of blood drawn
from the two ears have been compared, and there has been found a marked
difference in their actual chemical composition.

These considerations are interesting in connection with animal heat, as pro-
duced by the molecular changes in the various tissues, and appear, also, to
bear in some measure on the subject of the capillary circulation.

I shall hereafter take the ground that the capillary circulation is, in a great
measure, dependent upon an attraction of a chemico-vital character between
the tissues and the nutrient fluid.

Now, if the nutrition of the part be augmented, the congestion is due to
the greater attraction of the tissues for the blood, the capillaries being first
affected by its influence. The nutrition is affected, because the blood actually
undergoes greater change than on the other side. The capillary circulation,
then, in this case, seems clearly to be in a measure dependent on the process
of molecular regeneration and disintegration. There is no new action induced
in the part, but simply an augmentation of the usual processes ; and if this
be so, a cause of the capillary circulation is the chemico-vital attraction of the
tissues for the blood. The fact that there can be a greater supply of blood,
circulating with greater force, on one side of the body than in the correspond-
ing part on the other side, seems to me an insuperable objection to the idea
that the heart alone circulates the blood in the capillaries ; but I have antici-
pated, in some degree, the points which I shall hereafter consider more fully.

18 Flint, Phenomena of the Capillary Circulation. [July

When I commenced to describe the manner of making observations on the
capillary circulation in various parts, I asserted that destruction of the medulla
oblongata had no appreciable effect on the capillaries. Brown Sequard has
demonstrated, by experiment, that frogs are able to live perfectly well for three
or four months after extirpation of the medulla, and that all the functions,
except pulmonary respiration, continue to go on apparently as usual.

Before I met with these observations, I made two experiments with refer-
ence to the reliability of observations made on a frog after breaking up the
medulla or the posterior part of the brain.

In my first experiment, the posterior part of the brain was broken up in an
unsuccessful attempt to reach the medulla.

The circulation was observed for seven hours, and was but slightly retarded
when the experiment was concluded. For the first two hours, the circulation
appeared as usual. I have made numerous unrecorded observations on this
point, and have always arrived at the same result, i. e., I have introduced a
dissecting needle at the back of the head, sometimes reaching the medulla
and sometimes not, but always rendering the frog perfectly quiet and manage-
able; and I have been unable to discover any effects upon the circulation, or
the phenomena produced by irritants.

After making this experiment, I made several dissections so as to be able
to reach the medulla oblongata with certainty, and succeeded, in doing so,
in making the following observations : —

I examined the circulation for five hours with the same results as in the
preceding experiment, i. e., there was no alteration from the appearances of
the circulation in the uninjured frog, at least for the first two or three hours.

From these observations, added to my unrecorded experiments, I have no
hesitation in asserting that observations on frogs after breaking up the medulla
oblongata or the posterior part of the brain, are equally valuable with those
made on uninjured frogs; therefore, all the subsequent observations were made
after breaking up the medulla, unless otherwise stated.

Dr. Wilson Philip made an experiment which is interesting, though not
throwing any light upon the causes of the capillary circulation. " While Dr.
Hastings was observing the circulation, he crushed the brain by the blow of
a hammer. The vessels of the web instantly lost their power, the circulation
ceasing ; an effect which we have seen cannot arise from the ceasing of the
action of the heart. (Dr. Philip here refers to experiments by which it is
ascertained that the blood will circulate for several minutes after the interrup-
tion of the heart-action.) In a short time the blood began to move, but with
less force." I will here add the notes of a similar experiment performed by
myself. The brain of the frog was crushed while Prof. Flint was examining
the circulation, which was brisk and regular; the motion instantly ceased, but
commenced again in a few seconds, though it proceeded more slowly.

This observation thus in every respect confirms that of Dr. Philip.

This, as I have before remarked, cannot be thought to show that the capil«

1857.] Flint, Phenomena of the Capillary Circulation.

lary circulation is dependent upon nervous influence, but merely that a violent
shock is able to arrest momentarily all the vital functions. In several of my
observations, I have minutely recorded the appearances of the capillary circu-
lation, and have noticed the following phenomena : —

Observation 4th. I examined the web of a young frog.

From a careful and prolonged examination, it is evident that there is a dif-
ference between the modes of circulation in the arterioles and the venules.
The blood moves more freely in the former, and the motion appears to be
dependent on an attractive force — this is not as evident, however, here as in
the capillaries ; there the blood shoots off to different parts of the tissues in
a manner which cannot be dependent upon a " vis a tergo." It also moves
much more rapidly in some of the capillaries than in others, the velocity vary-
ing in the same vessel at different times. In the venules, the movement is
more sluggish, the globules apparently crowding each other along, and, on care-
ful examination, making a decided contrast to the movement in the arterioles.
The number of colourless globules is greater in the venules ; they adhere to
the walls of the vessels, and appear to be pushed along by the central mass,
moving very much more slowly, and occasionally remaining stationary for a
time.

Obs. 6th. In this observation, the same points attracted attention as in the
preceding one, and, in addition, the following phenomena : —

A small transverse capillary, admitting but a single globule at a time, was
abruptly bent at a certain point. The globules passed along in single file,
irregularly isolated from each other, and were bent nearly double in passing
the sudden turn in the vessel. This caused the globules to present a singular
appearance at this point; they seemed to move by volition, like animate beings.
The motion of the globules, under the above circumstances, is supposed to
denote an attractive force.

In several instances the walls of the vessels were distinctly seen ; they were
perfectly motionless, evidently taking no active part in the circulation. The
darting of single globules through small vessels, at a velocity greater than the
velocity of the circulation in the vessel from which they branch, was repeat-
edly remarked.

Obs. 7. The points noticed in Observation 4th were here confirmed. I
was forcibly struck with the great difference in the velocity of the circulation
in different parts of the field, both in vessels of the same size and of unequal
sizes. I also remarked a difference of velocity in the same vessels, especially
capillaries, at different times.

An attractive force is evident j a certain condition of the disks is necessary
in order that the force should operate. This condition, we may presume, is
effected by respiration.

The appearances of the capillary circulation in the web of the foot may be
described in the following manner : —

When the web is subjected to examination after the plan already stated,

20 Flint, Phenomena of the Capillar}/ Circulation. [July

we have vessels of various sizes in the field, consisting of arterioles and venules
which vary most in their diameters, and the true capillaries which are all of
nearly equal diameters. The blood is seen coursing along the vessels with
great rapidity, especially in the arterioles, where we may observe a slight
pulsatory movement.

In the arterioles, blood moves with unvarying rapidity as a general rule ;
and here especially we notice a space next the walls of the vessels, which is
not occupied by the red globules, but along which the colourless globules move
at a diminished rate, appearing to have a tendency to adhere to the walls of
the vessels, and sometimes even remaining entirely stationary for a time, to
be pushed along again by the central mass. This constitutes the still layer
of Dr. Kirkes.

The white or colourless corpuscles are much fewer than the red, and
they move at least ten or twelve times more slowly than the central mass.
On careful examination, I have been able to remark a decided difference be-
tween the circulation in the arterioles and the venules. In the latter the
movement is not so rapid, the globules appearing to be impelled more by a
"vis d tergo" and to feel less the "vis a fronte" which seems to operate in
the arterioles. The comparative number of the white corpuscles is greater,
but the " still layer" appears to occupy a smaller proportion of the calibre of
the vessel.

In the true capillaries, the movements are less regular, and apparently
dependent in a great measure on a force which acts directly upon them ; the
"capillary power," as it is designated by Dr. Carpenter. This will be more
fully touched upon presently, when we consider the causes of the capillary
circulation.

In the true capillaries, the blood moves in every possible direction, at dif-
ferent rates of speed in different vessels, also at different times in the same
vessel. In one instance, I remarked a capillary branching from a vessel at
an obtuse angle (that is, turning almost directly opposite to the current in the
main vessel), and individual globules shooting through it with great rapidity.
In many instances, I have observed an entire stasis in one or two of the capil-
lary vessels, but it existed only for a moment, and then recommenced with
its original vigour. Dr. Carpenter has remarked a stasis followed by a current
in a direction opposite to the original one.

It frequently happens that a globule is caught at the point of junction of
two vessels, and remains stationary until it is carried along by the current of
blood. G-lobules are frequently bent upon themselves as they pass from one
vessel to another, but as soon as the cause is removed, they regain their ori-
ginal conformation.

The walls of the vessel are motionless, and do not take an active part in
the normal circulation, as was supposed by some of the older writers.

Pigment-cells are observed scattered over the field, and when they are very

1857.] Flint, Phenomena of tlie Capillar?/ Circulation.

numerous, obscuring the view of the circulation ) therefore, it is best to select
a light coloured frog for demonstrations.

The pavement variety of epithelium may also be seen.

This is a description of the capillary circulation as it appeared to me under
the most favourable circumstances : more minute, but not otherwise differing
from the ordinary description in works on Physiology.

We now come naturally to a consideration of the causes of the capillary
circulation. I say causes, because I shall take the ground that it is not pro-
duced by a single cause, namely, the heart's contraction, as was supposed by
the great discoverer of the circulation. While it may be that the action of
the heart is sufficient to propel the blood through the whole round of the cir-
culation, as is contended by Magendie, by Dr. Allen Thompson, in the Cyclo-
pedia of Anatomy and Physiology Dr. Kirkes, and others, I believe that there
are other causes which operate, and are able to carry on the circulation unas-
sisted, as was the case in the acardiac foetus of Dr. Houston, reported in the
Dublin Medical Journal, 1837, where, of course, the circulation was stopped
at the birth of the child by the want of due aeration of the blood.

Harvey, followed by Magendie, Kirkes, and other eminent physiologists,
supposed that the heart was alone concerned in the production of the circula-
tion, and some very striking arguments were made use of to prove it, It is
found that, under the most favourable circumstances, a very inconsiderable force
is required to propel a bland fluid from the arteries through the capillaries
and out again by the veins. The pulsative movements, which we observe
under some circumstances in the capillaries, is also brought forward as an
argument. Dr. Kirkes dismisses the subject with the remark that "there is
no need of an hypothesis of any action of the capillaries for regular propul-
sion of the blood through them, nor is it probable they have such an office. "
This appears to me a most unphilosophical mode of treating a very important
subject. The circulation of the blood is a process immediately necessary to
existence, and even should we agree with him that the action of the heart is
capable of carrying on the circulation, it would not be out of place to inquire
if there were not some other force which also operates to this end, and could
take on, in some degree, the function of circulating the blood, should the heart
become weakened from any cause. We know that, in the performance of that
essentially vital function, namely, respiration, we commonly use but about one-
third of the entire capacity of the lungs, and though the lungs seem to be
only aerating organs, they divide that function with the skin. We might as
well say that, as the diaphragm is sufficient to carry on respiration, there is
no need of supposing that there are any other respiratory muscles. It is the
duty of the physiologist to endeavour to ascertain all the causes of any of the
vital phenomena.

There are several phenomena which are difficult of explanation by the theory
of the sole action of the heart in producing the circulation. In the first place,
it is difficult to understand how the heart could impel the blood through the

22 Flint, Phenomena of the Capillary Circulation. [July

second set of the capillaries in the portal system. Then the experiments of
Dr. Dowler show that the blood probably circulates in the capillaries, in
patients dead from yellow fever, after the heart's action has ceased.

In the frog, Dr. Carpenter asserts, and I have myself seen, that the blood
will circulate in the capillaries after complete excision of the heart. Carpenter
also mentions instances where the heart has suffered such a degree of fatty
degeneration, or replacement, that there existed scarcely a trace of muscular
fibre, and the circulation must have been chiefly dependent on the " capillary
power." Hassal records a most remarkable phenomenon, namely, the con-
tinuance of circulation in a portion of the tongue which had been entirely
detached from the organ. He states that, while examining the tongue of a
frog, a small portion was torn off, which he placed between two plates of glass,
and was astonished to see the circulation continuing in many of the smaller
vessels with unabated vigour. This phenomenon he observed for several hours,
in connection with several medical gentlemen, and, on examining it the next
day, preserving it under water in the mean time, the circulation still continued
to some extent. This seems almost incredible, but coming from such authority,
the fact cannot be doubted. Hassal appears to have made no subsequent
experiments with reference to this point. After seeing this statement, I made
two or three experiments, and once saw a slight movement in a portion of the
tongue entirely detached ; these experiments were not made, however, under
favourable circumstances, the weather being cold, and the frog in a state of
torpor, until partially aroused by immersion in tepid water.

A case is mentioned by Dr. Carpenter of an acardiac foetus which was sub-
jected to examination by Dr. Houston, where the organs were tolerably well
developed, with the exception of the heart, and the circulation could only be
effected by the "capillary power." These cases which I have described, are
amply sufficient to disprove the theory that the heart is the sole agent of the
circulation. In addition to them, the phenomena of inflammation as seen
under the microscope, the normal appearances of the capillary circulation,
which appear to the eye to be in some measure dependent on an attraction of
the molecules of the tissues for the blood ; the experiment of the section of
the sympathetic in the neck of the rabbit, which I have previously noticed,
and which produced an augmentation of this attractive force in the correspond-
ing ear and side of the face, and comparison with the circulation in some
aquatic plants, which we know is not dependent upon the action of a heart,
all these go to prove that the heart alone does not produce circulation.

Prof. Draper, of the University of New York, has put forward a theory in
regard to the circulation, which makes the heart of minor importance. His
is the theory of capillary attraction and affinity. He starts from the proposi-
tion that, "if two liquids communicate with each other through a capillary
tube, for the substance of which they have affinities of different intensities,
movement will ensue \ the liquid having the highest affinity will occupy the
tube, and may even drive the other from it ; the same effect will ensue in a

1857.] Flint, Phenomena of the Capillary Circulation.

porous object." He believes that this is the great cause of the circulation,
namely, an affinity between the blood and the tissues ; that thus the blood is
forced into the veins, and that the action of the heart is limited to filling the
arteries and presenting a supply of blood to the capillaries. The blood circu-
lates in the lungs chiefly from its affinity for oxygen.

This theory cannot be sustained. The heart undoubtedly has a much more
important office in the production of circulation. When we cut a small artery,
we see the blood forcing itself in a jet to a distance of several feet; and this
happens after it had entirely lost the influence of the capillary force. The
illustration of Prof. Dunglison, namely, the law that fluids confined in tubes
will rise to the same level, and that thus the blood in the veins, by a simple
hydrostatic principle, would rise as high as the right auricle in a line with the
blood in the left ventricle, shows how slight a force from the heart would be
propagated through the capillaries to the veins, and be sufficient to return the
blood.

Dr. Dowler, -of New Orleans, believes in a distinct capillary action. In
some of the experiments which he adduces in support of his position, and
which are noticed by Dr. Dunglison in his Human Physiology, bodies of yel-
low fever patients were carried to the dissecting room a few moments after
death. " The external veins sometimes became distended, and when punc-
tured, the blood flowed in a good stream ; the operation of bleeding at the
arm was imitated, and as the muscles were moved, the blood shot forth for
some distance." Other experiments on the veins, of a similar character, are
recorded by him.

These observations seem to show that there is some action in the capillaries
after death, and inferentially during life, which is independent of the heart's
action. The entire emptying of the arteries after death cannot be perfectly
explained by the mere contraction of the vessels.

What causes seem to operate to produce the capillary circulation, judging
merely from the appearances under the microscope? In the observations
which I have recorded on this point, we have noted an irregularity of the
movement in the capillaries, both in different vessels at the same time, and
in the same vessel at different times; the irregularity sometimes amounting
to entire cessation of the circulation in a single vessel, and then a current in
an opposite direction ; a shooting off of single globules through vessels which
were before empty, the darting off of globules through capillary branches
with a velocity greater than that of the blood in the main vessel; and in short,
all the phenomena which are presented to the eye, seem to indicate that there
is an attractive force, resident in the solid particles, which operates on the
blood in the capillaries.

We are not supposing the existence of a force with the operation of which
we are unacquainted. The present school of physiology teaches us that the
processes of nutrition, of molecular disintegration, and of secretion, are depend-
ent on a vital force resident in the solid particles of the organism, which are

Flint, Phenomena of the Capillary Circulation. [July

essentially vitalized. Inflammation is now supposed to be due to a perversion
of this force.

In what other way could we explain the fact that every tissue takes from
the mass of arterial blood the substances which are required for its nutrition.
The blood sent to the systemic capillaries by the heart is the same in all parts
of the body, but when the great change which is effected in the capillaries
has taken place, we find that the blood which has thus been rendered venous
is not the same in all the veins; for example, the blood in the renal vein is
almost as florid as arterial blood.

The existence of a distinct capillary action is now believed by the highest
authorities. Lehmann believes that a chemico-vital attraction of the blood
for the tissues, together with the physical capillary attraction, produces the
movement of the blood in the capillaries, and forces it into the veins. Dr.
Carpenter believes that there exists a "capillary power" which is superadded
to the force of the heart. Prof. Dunglison teaches that there is an independ-
ent power resident in the tissues about the capillaries, and that, "by the
united action of the heart, arteries and capillaries, or intermediate system of
vessels, the blood attains the veins." Even those who recognize the heart as
the only efficient organ of circulation yield that the capillaries possess a
"distributive force;" that is, though the circulation is effected by the heart's
unassisted action, that the tissues have an attraction or affinity for the blood,
which distributes it for their nutrition to each and every part of the body.

Taking into consideration everything which I have seen bearing on this
point, it seems to me to be clearly proved that the normal capillary circulation
is dependent, in the first place, on the action of the heart. It cannot be
denied that the heart has a considerable share of the duty of capillary circula-
tion. Taking into account the conditions of the blood and vessels, apparently
a slight force is capable of propelling the blood through the capillary system.
When a small artery is divided, the force with which the blood pumps out is
considerable, and appears sufficient to exert a decided effect on the motion of
the blood in the capillaries. It is impossible to estimate with much accuracy
the proportional influence which the heart has in producing capillary circula-
tion. The vital affinity between the tissues and the blood, which I suppose
to be the other power concerned in this function, never ceases ; still, as the
action of the heart is frequently much interfered with, as in cases of exces-
sive fatty degeneration, and as the heart has been removed from the frog, the
capillary circulation nevertheless continuing, we cannot think that its power
is greater than the attractive force, or Carpenter's "capillary power," which
I hold to be essentially concerned in the performance of this function. The
value of the heart's action is also variable, both in different individuals, and
in the same individual ac different times.

The only other force which has any share in the production of the capillary
circulation, unless it be a slight suction force from the veins, is the "capillary
power." This seems to me to play the more constant and effective part.

1857.] Flint, Phenomena of tlie Capillary Circulation. 25

When this ceases to act the animal dies, and the blood refuses to circulate in
spite of the heart. This is the great vital force of nutrition which is con-
stantly operating, and which is so wonderful and inexplicable. We know the
fact that there is such a force, and that it continually acts, but what it consists
of, or what is its essential character, is beyond the wisdom of man to explain.
It is life. Lastly, the following inquiry suggests itself : What conditions are
necessary to the healthy performance of the capillary circulation ?

First, a healthy condition of the vital particles, which is produced by
healthy nutrition. Secondly, a particular condition of the blood, which is
produced by respiration.

No arguments appear to be necessary to prove the former statement, but I
have made experiments, which I shall proceed to describe, which conclusively
establish the second point.

The following experiment, made by Dr. J. Reid, and reported in the Edin-
burgh Med. and Surg. Journal, April, 1841, is quoted by Dr. Carpenter: —

Dr. Reid found that when the ingress of air through the trachea of a dog
was prevented, and the asphyxia was proceeding to the stage of insensibility,
the pressure in the femoral artery, indicated by the hsemadynamometer, was
much greater than usual.

Upon applying a similar test to a vein, however, the pressure was propor-
tionally diminished, whence it became apparent that there was an unusual
obstruction to the passage of the venous blood (the blood being venous in the
arteries) in the systemic capillaries.

Before seeing an account of this experiment, I had made the following
observations, carefully recording them, with reference to the same point : —

Obs. 1st. The medulla of a middle sized frog was broken up, and the web
submitted to microscopic examination. The frog was bathed with sulphuric
ether, care being taken not to allow any to touch the web under examination,
and the circulation was watched for ten minutes. No effect could be dis-
covered. The object of this experiment was to determine whether the phe-
nomena in the succeeding experiment were in any degree dependent on the
ether which is contained in collodion. The frog was then painted over with
an impermeable coating of collodion, care being taken as before not to touch
the web. The effect on the circulation was immediate. It instantly became
less rapid, until, at the expiration of twenty minutes, it had entirely ceased.

The smaller vessels were the first to become affected, the larger arterioles
resisting it longest. One of the first effects was a pulsative movement in ves-
sels where the blood had previously flowed in a continuous stream, showing,
as it seems, that the attractive force is lost, hut that the heart's action is felt.
The fact of the first arrest of the blood in the capillaries, seems to indicate
that the blood is now unfit to supply wants of the tissues, and that the attract-
ive force ceases to be operative. The arrest of the circulation was steady,
and at the expiration of twenty minutes the motion had entirely ceased.

26 Flint, Phenomena of the Capillary Circulation.

The entire coating of collodion was now instantly peeled off, and the effect
on the circulation was instantaneous. Quite a rapid circulation immediately
commenced, but it soon began to decline, and in twenty minutes had almost
ceased. The heart was now exposed, and found contracting regularly. In
this experiment, all respiration was abolished, the medulla being broken up,
and an impervious coating applied to the entire surface.

Obs. 2d. I painted a frog with a thick coating of collodion, without
destroying the medulla. It struggled vigorously at first, but soon became
quiet, and the web was put under the microscope.

The circulation was affected in the same manner as in the preceding experi-
ment, and entirely ceased in twenty-five minutes.

During the first few minutes, the nostrils dilated and contracted rapidly,
but soon became motionless. Care was taken not to obstruct the nostrils
with collodion, though it was applied effectually to all other parts excepting
the foot under observation.

The experiment of Dr. Reid proves the fact inferentially, namely, that the
blood, deprived of oxygen, as in asphyxia, is retarded in the systemic capil-
laries ; but the experiments just related, bring the processes directly under
the eye, and we can see clearly that when the blood is not aerated it will not
circulate, though the heart contracts, and that it is retarded in the capillaries.
My second experiment demonstrated the comparatively small part which the
lungs of the frog take in respiration; the blood circulating in the frog, in
which the pulmonary respiration was not interfered with, only five minutes
longer than in the frog after destroying the medulla. Capillary circulation
will go on in the lungs of the frog after tying the trachea, as I stated when
describing the circulation as seen in various parts of the animal, the blood
being sufficiently aerated by means of the skin.

Thus it is experimentally proved that an oxygenated state of the blood is
an indispensable condition for its circulation through the capillaries. When
the process of respiration or aeration of the blood is established, the blood
cannot circulate. This we know to be the fact, but we demonstrate, by the
preceding experiments, that, in asphyxia, the impediment to the circulation
takes place in the capillaries ; that the condition of oxygenation is necessary
to the performance of the vital functions, and it may be that the entire want
of the "capillary power" throws all the onus on the heart, and that the heart
is insufficient for the labour. In one of my experiments, after the capillary
circulation had entirely ceased, the chest was opened, and the heart found
beating regularly.

1857.] Schneck, Treatment of Scarlatina by Diluted Acetic Acid. 27

Art. II. — On the Treatment of Scarlatina by the Diluted Acetic Acid. By
B. F. Schneck, M. D., of Lebanon, Pa.

During the past twelve or fourteen months a severe epidemic of scarlatina
has prevailed in my neighbourhood. Of 190 cases of the disease treated by
me in accordance with the method recommended by our best authorities, I lost
1 in 8J to 9.

Dissatisfied with this result, I was induced to try the diluted acetic acid as
recommended by Dr. I. B. Brown, whose work1 I had the good fortune to
meet with at the commencement of the present year. Of 60 < cases treated
subsequently by this plan, I did not lose one. The disease at this time had
not undergone any abatement from its former violence ; for among the sixty
recoveries there were cases of such malignancy, as would inevitably have
perished under the best directed previous efforts. It is true that two of the
sixty afterwards died of thoracic and cerebral dropsy ; and one, after a nearly
two weeks' convalescence, from purpura hemorrhagica, with epistaxis, hgenia-
turia, &c. ; but these cases cannot be regarded as affecting the integrity of the
plan in question. I am thus enabled to bear a flattering testimony to the
success of Dr. B.;s method.

Many medical men, after unsatisfactory trials of all the ordinary modes of
treatment, now declare that the less there is done for scarlatina the better.
All such will be apt to think lightly of Dr. Brown's method ; if, indeed, they
do not condemn what they may choose to call his nimia cura medici. Let
such rest assured, however, that this is a disease which, like weeds, flourishes
most when least attended to ; and further, that the character of medical adviser
must be merged, for the time, in that of nurse also, to a certain extent, if his
ministrations are to be successful. He should see his patients several times in
a day — the oftener the better; and, following the example of our author, he
should even be found holding nightly vigils by the bedside, if the urgency of
the case required it. The daily dressings of the fauces with caustic should, if
possible, be made by himself ; he should direct the frequency of the repetition
of stimulants; and even the minutest details should ever be under his imme-
diate cognizance. Thus fully occupied, although he may be able to take charge
of fewer patients, he will save more lives; and only thus will he be able to
realize the truth of the otherwise almost incredible statement of a friend of
the author's engaged in extensive practice, who writes, " that the number of
fatal cases occurring to him under this treatment did not exceed four." This
gratifying result, it is the writer's firm conviction, will be the reward of all
who will adopt and faithfully carry out the plan.

1 On the Treatment of Scarlatina by the Acidum Aceticum Dilutum of the Pharma-
copoeia. By h B. Brown, M. D. London, 1846.

28 Schneck, Treatment of Scarlatina by Diluted Acetic Acid. [July

The following is a synopsis of Dr. Brown's views : —

1. Scarlatina is always and essentially a disease of debility, or tending to
debility, and not of an inflammatory nature. Its poison acts primarily and
most fatally upon the blood, producing a dissolved, semi-vitalized and putres-
cible condition of that fluid ; so that it posesses more serum and less fibrin
than in its normal state. " Consequently the serum percolates, or is effused
into the cellular tissue and cavities, through the coats of the vessels. Salines
favour this dissolved state of the blood ; but acetic acid prevents the separation
of the serum from the fibrin."

2. Acetic acid is an excellent antiseptic; "it gives tone to the blood in
scarlatina, and prevents the separation of the serum from the fibrin." It also
" acts as an astringent upon the lymphatic system and serous membranes, and
so effectually prevents dropsy."

3 . It is a grateful refrigerant.

4. No medicine has a more decided influence in promoting digestion than
this acid. We are further directed, while administering it, to " allow pa-
tients almost anything they fancy; it will seldom hurt them in severe and
even dangerous disease."

These four points lie at the foundation of Dr. Brown's very simple and
very successful treatment. The specialities of his method will now be given,
as applicable to the several forms of the disease.

Whatever may be the type, he prepares the system for the acid, by giving

1. An aperient of 3 to 5 grs. of calomel, to be followed in two hours by
castor oil. All saline aperients are condemned; " salines favour a dissolved
state of the blood." If, from great gastric irritability, the oil is rejected, he
recommends an aperient mixture (rhubarb and magnesia), which contains no
saline substance.

2. Apply a piece of flannel round the throat from ear to ear, saturated with
soap lin. f^j; camphor lin., laudanum, aa ^ij.— -M.

3. After the operation of the oil, give — for a patient nine years old — dis-
tilled vinegar, diluted, * f^j ; syrup f5iv; distilled water f^iv. — M. Two
tablespoonfuls every four hours. This mixture is to be continued throughout
the entire duration of the case, whatever the form of the disease ; and for
one or two weeks afterwards, or until desquamation is well over. "It acts
as an astringent upon the lymphatic system and serous membranes, and so
effectually prevents dropsy."

4. Whenever, in scarlatina simplex, there is slight delirium in the begin-
ning, with a thick, viscid phlegm on the tonsils, apply daily — nitr. silver grs.
x; distilled water f^j. — M. You thus prevent s. anginosa. If the throat
require it, a linseed poultice may be placed over the flannel, and kept there
constantly.

5. On the third or fourth day, in simple cases, allow mutton-broth.

1 R. — Distilled vinegar, offic., one part: water, seven parts. — M.

1857 ] Schneck, Treatment of Scarlatina by Diluted Acetic Acid. 29

6. As soon as desquamation comes on, order a warm bath or two, and keep
the patient strictly in bed during the whole process.

S. Anginosa. — Here the treatment is the same, except that the caustic
must be used more frequently, and the proportion of acid in the solution
must be increased. A good rule is to increase the strength according to the
violence of the attack, in bad cases giving it as strong as the patient can take
it. Poultices to throat. Should symptoms of adynamia come on, give arrow-
root, with a spoonful of brandy in it; add comp. sp. ether to acid solution;
wash face, hands, legs, and chest with tepid vinegar (£) and water (f). If
restless at night, give tinct. hyoscyam., or ^ to J gr. morphia, according to
age. The decoction of bark may also be added to the acid mixture. When-
ever, in s. anginosa, symptoms of adynamia come on, dress the throat fre-
quently with caustic, and increase the quantity of acid from day to day ; you
thus prevent s. maligna.

For adults, in cases partaking of the nature of s. maligna, the following
formula is given: R. — Distilled vinegar {$iv ; syr. red poppies f5iv; dis-
tilled water f^iv. — M. One-fourth part to be taken every four hours.

In s. maligna the same course of treatment is to be pursued ; calomel, oil,
caustic, acid mixture (strong), liniment or sinapism to throat, followed by
poultices ; brandy or port wine every four to six hours, with arrowroot, beef-
tea, or mutton-broth; morphia at bedtime, or whenever restless, and sponging
with tepid vinegar and water. All the bed furniture, carpets, &c, to be
removed from the room, and chloride of lime to be sprinkled about the floor.
During desquamation, the patient is not to sit up at all. Give at this time
one or more warm baths. Use wine and brandy in s. maligna, even in the
febrile stage; when combined with the acid, which so powerfully assists
digestion, no harm will ever accrue from their use.

This is a brief statement of Dr. Brown's views and practice in this terrible
malady. To the work itself we must refer for a number of valuable cases,
illustrating most happily the treatment which he advocates, and interspersed
with many highly practical remarks. I cannot help transcribing at length,
as a fitting close to this portion of the subject, the following observations,
which I have copied from his work : —

''Very much depends on careful watching in this disease ; there is always, in
one or the other of the stages, a critical moment. For instance, in the eruptive
stage, even in s. simplex, delirium will come on, and the throat will become more
clogged with viscid secretion in a few hours ; and if attention be not promptly
given, and this phlegm, which impedes free respiration, be not removed, the
delirium and laborious breathing will increase, and the disease will soon run
into the second or anginose form. In this case, the throat must be promptly
cleansed, and some gentle nourishment be given. Again, in s. anginosa, it will
not seldom happen that the tonsils and fauces will suddenly become worse, or
great sickness or sudden prostration will come on ; now, unless the throat be
instantly attended to, delirium, laborious breathing, difficult deglutition, and
restlessness will make serious ravages upon the patient, and all remedies will
quickly become unavailing ; or, where sudden prostration should arise, then we

No. LXVIL— July 1857. 3

30 Schneck, Treatment of Scarlatina by Diluted Acetic Acid. [July

must promptly and unsparingly administer stimulants and cordials till the pulse
exhibits more steadiness and power."

The practical importance of these directions cannot be over-estimated. As
assisting the cleansing of the fauces from viscid secretions, I have, for several
years past, been in the habit of injecting the diluted chlorinated soda into the
nares, with the happiest effects. Extensive ulceration, not only of the pos-
terior nares, but of the entire nasal tract, with an abundant secretion of a
peculiar tenacious mucus, are an attendant on every bad case; and these
passages cannot be long obstructed without great distress and imminent dan-
ger. The daily or bi-daily injection of Labarraque's solution, therefore, while
it effectually clears away the obstruction (as any other liquid would as well),
exerts besides an alterative and healing influence upon the ulcerated surface
itself ; and it destroys, while it removes, the morbid products which, if swal-
lowed, as they are otherwise sure to be, disturb so seriously the intestinal
canal ; and last, but not least, it corrects the fetor which is so disagreeable a
concomitant of such cases. So signal is the relief derived from this pro-
cedure, that, unpleasant though the sensation must be, I have seen the little
patients, instead of shrinking from the operation, instinctively court the repe-
tition of it, and if old enough, ask for it. It is a measure which, in the class
of cases referred to, cannot be dispensed with, without loss. But as it may
happen that a considerable quantity of the injection may be swallowed, and
the blood be thereby impaired, it will be proper always to precede or follow
the injection with a strong dose of acetic acid, so as to neutralize the saline
ingredient.

The preparation of the acetic acid solution may be varied somewhat from
the formulas given above, and so simplified, without in the least affecting the
result. Instead of first diluting the concentrated acid to the strength of vine-
gar, and then using the dilution for the preparation of the solution, I have
been accustomed merely to add from f5j to f3iv of the officinal acid to f^iv
water, and ordering a tablespoonful overy few hours, sweetening at the time
of administering it. We must, however, never forget to increase the strength
in proportion to the threatening nature of the symptoms.

In the use of stimulants, also, a little license has been taken with our
author's directions. Having ventured upon the guarded employment of
brandy, beef-essence, &c, as a precautionary step, earlier in the attack than
he allows, without detriment, I now administer brandy in graduated doses,
two or three times a day from the beginning in the malignant form, or on the
second or third day in anginose cases; and I have seen no reason to regret this
course. If the tongue becomes red like a strawberry, with the papillae as large
as a pin's head, or on the contrary, brown, dry, fissured, with sordes on the
teeth; and if there be, besides, a recession of the eruption, a pulse fluttering
and not to be counted, or even delirium, " then we must unsparingly admin-
ister stimulants and cordials, until the pulse exhibits more steadiness and
power." Carb. ammonia, quinia, and even capsicum, have here all failed me ;

1857.] Schneck, Treatment of Scarlatina hy Diluted Acetic Acid. 81

this last having proved alike ineffectual as an arterial stimulant, and as a local
application to the fauces.

If scarlatina were an inflammatory disease, as the advocates of bleeding and
antiphlogistics would have us to believe, such a stimulant course could not
fail to result disastrously in nearly every instance; but the reverse is actually
the fact. The violent excitement in severe attacks, as indicated by burning
skin, rapid pulse, delirium, &c, is not an evidence of phlogosis, but of irrita-
tion. And when death takes place in such cases, it is not so much from in-
flammatory disorganization of any vital part, as from sheer exhaustion; the
inevitable consequence of the excitement into which the system had worked
itself, in its vain struggles against the fatal poison which was oppressing it.

Dr. Brown's silence in regard to the use of emetics is a significant fact ;
although more celebrated authorities than he, recommend them highly. Their
adoption at all, as part of the treatment, was probably suggested by the nausea
and vomiting which almost always usher in the attack ; under the supposition
of the presence of acrid ingesta, which they were designed to remove. It may
be, that when the mildest article is selected, solely with this view, they may
do no harm ; but when administered indiscriminately, fatal results must occa-
sionally follow the practice.

Dentition, improper food, the hot months, and a hereditary predisposition,
may all, in scarlatina, favour the occurrence of serious gastro-intestinal dis-
ease, from the least exciting cause ; and an emetic, especially if containing
tart, antimony as advised by some, may be this cause. In the month of July,
1856, I was called to see a child aged 20 months, ill with s. anginosa, run-
ning into maligna, with scarcely any eruption. Notwithstanding the child
had vomited, an emetic of ipecacuanha with calomel was given, after a
warm bath ; to be followed by sp. nitric ether and bicarb, soda in solution,
with capsicum infusion. The vomiting became unmanageable, attended with
a copious diarrhoea ; gastritis supervened, with peritonitis and enormous ab-
dominal distention ; and on the fourth day the child died in convulsions. The
emetic most probably had killed it.

What, let us ask, does the gastric irritability of this disease mean ? Is it
not the first appreciable alarm given by nature of the introduction of the
poison, and an ineffectual attempt on the part of the system, to get rid of it
at the outset ? But as the morbific matter is introduced, and the blood satu-
rated with it, many days it may be before it actually develops itself, how can
we expect emesis, whether spontaneous or artificial, to dislodge it ? If, instead
of vomiting, scarlatina began with diarrhoea, would we be justified in giving
an active purgative, with the same object ? Assuming Dr. Brown's view to
be correct, would it not be malpractice to bring to bear the depressing effects
of a nauseating emetic upon a disease whose tendency from the beginning is
towards debility ? The unfortunate result above related has convinced me that
the use of emetics, as a matter of routine, is fraught with great danger; and

32 Schneck, Treatment of Scarlatina by Diluted Acetic Acid. [July

that their employment is indicated in very few, and very special cases, if at
all.

The following cases, representing the worst forms of s. anginosa and malig-
na, are selected out of a number of similar ones, from my case-book, as illus-
trating the gratifying success of the acetic acid treatment, even when under
the most unfavourable circumstances.

Case I. — Dec. 27, 1856. Saw a girl of Jos. Heilman, aged 13, in an at-
tack of s. ang. threatening maligna. On the evening of the 28th found more
fever, very frequent, angry pulse, constant sighing and heaving of the breath,
with increased impulse of heart. Suspicion of pericarditis, and tempted to
bleed. Concluded to postpone till next morning; ordering sinapisms to ex-
tremities, and dose calomel. Was prevented from seeing her until next day
towards evening.

29th. Pericarditis now clear. Bled viii oz. ; epispastic to left chest ; cal.
and op. aa \ gr. every 2 hours ; sinapisms to extremities. Eruption well out.
Teaspoonful brandy at one, to be continued 3 or 4 times a day, with beef-
essence.

30^/i. Effusion around heart; impulse scarcely perceptible to hand, or
audible ; at times delirious ; eruption well out ; slight epistaxis. Inunction
with mercurial oint., and same to blister. Continue remedies.

31st. Homing. Pulse more full, and a shade slower; impulse of heart more
perceptible, and less muffled ; had 3 or 4 evacuations. Continue treatment,
with alternate doses of pulv. scillse and digital., aa J gr., cal. \ gr.

Evening. Cardiac trouble decidedly better; but alarming prostation, from
epistaxis to the extent of a pint. Partial coma ; tongue dry, and papillae very
much elevated ; four alvine discharges. Cold cloths to head and neck ; Dover's
p. 3 grs., digital. £ gr., acet. lead \ gr. every 2 hours (having omitted former
powders); 10 drops elix. vitriol every 2 hours. Sinapisms to extremities;
iced lemonade for a drink ; may die to-night.

Jan. 1, 1857. Morning. Bled a pint or more at two several times, to-night;
extremely exhausted ; but one dose of the medicines ordered last evening was
given ; family expecting her death hourly. This being contrary to my express
orders, I at once directed a resumption of the treatment, including brandy
and essence of beef.

Evening. Has taken remedies all day ; no bleeding. Pulse a little fuller,
and slightly slower. Tongue dry, and covered with crusts of blood. Erup-
tion apparently about to decline on upper part of body, but well out on lower
extremities. Continue treatment, at three hours' interval.

2d Noon. Pulse a little slower ; circumscribed flush on each cheek ; face

sunken ; tongue very dry ; skin dusky, and whole case typhoid. Turpentine
emulsion and elix. vitriol, with beef-essence, and brandy and milk.

3d. Tongue a little more moist. Continue remedies.

4th. Improving ; pulse a little slower. Will recover.

bth to Qth. Has great appetite. Slowly convalescent.

Remarks. — Bleeding, in scarlet fever, is not necessarily an injurious mea-
sure, especially if its otherwise depressing effect be guarded against, imme-
diately afterwards, by suitable doses of stimulants and nourishment. In this
instance, the venesection most assuredly saved life, by moderating and favour-
ing the resolution of the cardiac inflammation ; which, although it had gone

1857.] Schneck, Treatment of Scarlatina hy Diluted Acetic Acid. 33

on to the effusion of serum, was nevertheless relieved by it, and by the sub-
sequent use of squill, digitalis, and calomel. The recession of the eruption,
which might otherwise have fallowed the bleeding, was also prevented by the
prompt administration of small doses of brandy. In a similar case of peri-
carditis in the course of scarlatina, I should feel emboldened to bleed largely,
giving stimulants and beef-tea generously immediately afterwards, as the only
mode promising success.

Case II. — S. Anginosa running into Maligna Dec. 30, 1856. Girl of

Geo. Strohm, aged 4 years. Vomiting; very rapid, irritable pulse; eruption
of a vivid red colour; tonsils greatly enlarged, and covered with lymphy ex-
udations. Solid caustic to throat; cal. oil, and strong acid solution.

Jan. 1, 1857 — Morning. Symptoms of great malignancy; fauces of a dark
purple hue ; face mottled with white patches, where the eruption showed a dis-
position to recede ; excessive restlessness all night, getting out of bed in the
delirium ; surface of an intensely deep red colour ; pulse rather feeble, and
slow. Solid caustic to throat; sinapism externally, to be followed by poultices.
Teaspoonful of brandy every five or six hours, if not gone to sleep. Beef-
essence ; acid solution stronger.

Evening. Has slept some hours ; face more uniformly red; pulse more fre-
quent; surface hot. Sol. 10 grs. nitr. silver to ^j water, to fauces twice a day;
chlorinated soda injections into nares. Continue remedies.

2d. Same as last evening. Comp. camph. lin. to throat, which is much
swollen ; caustic, injections, brandy, and beef-tea.

3c?. Desquamation already beginning on different parts of the body, being
only the fifth day — a bad sign. Continue remedies.

ith. Throat very much swollen externally ; tonsils deeply ulcerated ; case
very malignant ; sinking, and very restless ; surface pale and cool.

10 P. M. Was sent for; supposed to be dying. Prognosis very bad. Solid
caustic to throat ; injection into nares ; brandy every two or three hours, and
continue remedies.

hth. Pulse a shade slower. Family did not attend to throat this morning.
Applied caustic at once, and injected chlor. soda into nares, bringing away large
masses of viscid secretions, with great relief. Quite rational.

6th to 10th Pulse slower. Gradually convalescent.

Remarks. — This case exhibited what I have repeatedly seen in this epi-
demic— a succession of pure white patches in the midst of the eruption, on
the face most generally; appearing in the course of a few minutes, and per-
sisting sometimes for half a day, or longer. Having met with this symptom
only in cases of a malignant character, with a cool skin, and other signs of
adynamia, I have come to regard it as an indication for the prompt use of
stimulants.

The early occurrence of desquamation in this case — on the fifth day of the
eruption — is also worthy of note, as indicating great pravity of system. In
September, 1856, I met with a case in which desquamation began, all over
the body, in extensive patches, on the fourth day of the eruption. The skin
was as though it had been seethed or scalded ; the cuticle separating first at
the points of pressure from the motions of the patient, incident to her changes

34 Schneck, Treatment of Scarlatina by Diluted Acetic Acid. [July

of posture in the delirium — as the elbows, hips, &c. — but finally comiDg away
wherever the clothing lay in contact with it. These denuded surfaces were
literally raw; when recent, serum standing upon them in minute drops. The
patient, a girl of 15 years, died rapidly of pericarditis.

Case III. — Purpura folloiving S. Anginosa and Maligna. — Feb. 23, 1857.
In this instance, as in a considerable number of others in this epidemic, I ob-
served that the eruption on the arms was most fully out along the course of
the nervous trunks, there being a broad belt, of an intensely red colour, in the
line of the bloodvessels and lymphatics, from the hand to the axilla. Having
never seen this symptom noticed, and having observed it only in the worst
forms of the disease, I have been led to regard it as indicating either phlebitis,
or inflammation of the absorbents, and, as such, a serious complication of the
case. The details of this case are very similar to those previously given, and
hence need not be gone over. It is sufficient to say that the child recovered
with the greatest difficulty ; but by the end of the first week of March he was
clearly convalescent, although greatly reduced, and very pale. He, however,
took nourishment, with acid mixtures, and it was hoped he would do well.

March 13. I was informed this morning that his mouth bled slightly, and
that the blood appeared to ooze from the gums. Sent him tinct. chlorid. iron,
and saw him in the afternoon. Found that epistaxis had set in ; the blood
looking pale red in colour, like a mixture of currant-juice and water. Purpura
patches had appeared over the whole of the lower extremities. Prognosis very
unfavourable. Beef-essence and elix. vitriol at short intervals, alternating with
sol. potassio-tartr. iron.

14th. Gretting worse rapidly. Purpura on arms and breast. In the course
of the day, vomiting of coagulated blood, which had evidently passed into the
stomach from posterior nares. Vomiting continued ; everything was rejected;
and in the afternoon, after having passed some bloody urine, the child died,
perfectly blanched.

Remarks. — This case is interesting, as confirming, to some extent, Dr.
Brown's views of the pathology of scarlatina. Here was, first, a deficiency of
red globules in the blood, as was evident from its pale red colour. We infer,
also, an increased tenuity in this fluid, as manifested by the hemorrhagic tend-
ency, and which may have been caused either by a deficiency of fibrin, or a
preponderance of serum, from paucity of red corpuscles. However we may
explain the morbid result, the occurrence of purpura is almost inexplicable
under the constant administration of the strongest nourishment and acid solu-
tion, unless we admit the coexistence of the scarlatina poison, acting upon the
blood to bring it into this dissolved state. At least, this was not congestive
or inflammatory purpura.

Would it not be advisable, in every case of s. anginosa and maligna, espe-
cially the latter, to administer, as soon as the disease has subsided, and des-
quamation is beginning, a mild preparation of iron? Might not the fatal
termination in this casj perhaps have been averted by the earlier employment
of a ferruginous tonic? Further, would not also the iron, by increasing the
crasis of the blood, lessen the chance of dropsy? Or, on the other hand,
would the iron be capable of increasing the tendency to dropsy, by rendering

1S57 ] Schneck, Treatment of Scarlatina oy Diluted Acetic Acid. 35

the blood inflammatory, and so favouring the renal disease, which is so promi-
nent a symptom (if not the cause) of the dropsy ? This is quite possible,
regarding, as I do, the condition of kidney in the dropsy of scarlatina as a
real, though temporary, acute Bright' s disease.

Supposing, however, as does Dr. Brown, that the watery condition of the
blood after scarlatina is the cause of the effusion, how can we reconcile with
this the benefit derived from venesection in dropsy? If this supposition be
correct, are we not, by the abstraction of blood, and the consequent still fur-
ther impoverishment of that fluid, increasing the tendency to effusion ? In-
stead of which, we find the swelling mostly soon to disappear rapidly after
bloodletting. At least, such has been my experience, repeatedly, in bad cases
of cerebral and cardiac dropsy ; and Watson, in similar cases, gives bleeding
his unqualified approval.

These facts militate strongly against the causation of dropsy, as explained
by Dr. Brown. For the present, then, we know of no solution of the diffi-
culties presented to us above, and must be content to follow apparently oppo-
site indications, if correct and successful, without being able to reconcile
differences.

Case IY. — Scarlatina in Childbed. Scarlatina Neonati. — On the 2d of
July, 1856, I was requested to see the wife of Fred. Schaffer, in an attack of
s. anginosa. She was at the end of her pregnancy, and expected her confine-
ment daily. Both of her children had just passed through a severe attack of
the disease, and she had been their only nurse. Knowing the disastrous con-
sequences to be apprehended from scarlatina during confinement, I undertook
the case with no little anxiety. On the 4th, the premonitory symptoms of
labour appeared, which I treated with anodynes, hoping to put off the evil day
as long as possible. Moreover, dreading the exhaustion which would be likely,
in such a case, to follow the excitement of labour, and still more the debility
consequent upon the lochia (which would act as a drain upon the system), I
sought to prepare the patient for the crisis by moderate doses of carbonate of
ammonia, serpentaria, and beef-essence. By a cautious use of opiates, the
labour was kept off until the afternoon of the 6th, when the woman was de-
livered of a mature female child, which, however, lived only three or four
hours. This child was covered from head to foot with the eruption, of an in-
tensely red colour ) and, lest I might have mistaken the naturally florid colour
of many newly-born children for scarlatina, I examined the fauces, and was
surprised to find prominent anginose symptoms, and the soft palate thickly
studded with red points. The infant soon became cold, and the eruption
changed to a purple hue, which, before death, gave place to an almost indigo
colour.

My precautions in regard to the mother proved to be well-timed. In addi-
tion to the supporting plan adopted before confinement, she now bore well a
generous supply of wine. She made a good recovery ; but, a week afterwards,
was attacked with subacute rheumatism of the wrists, which yielded to Dover's
powders and vinum colchici.

Remarks. — Bamsbotham, in his work on Parturition, highly recommends
a stimulating and supporting treatment of the scarlatina of puerperal women,

Earle, Partio- General Paralysis.

[July

as the only method likely to prove successful ; and the above case is interest-
ing, as confirming not only his own views, but also those of Dr. Brown. Mor-
ris, in his Lectures on Scarlet Fever, says that "to pregnant and puerperal
women it is almost inevitably fatal. I have known several cases which proved
mortal, but have never heard of a recovery/7

These cases, from my own observation, must suffice for my present purpose.
They confirm, and correspond with, Dr. Brown's teachings and cases very
fully ; and this correspondence between two epidemics thus widely separated
as to time and space is certainly more than a mere coincidence. It seems to
indicate a certain general principle, which underlies, and so essentially deter-
mines the nature of this, as of every other affection, through all the variations
of climate, locality, and prevailing type of disease. Whether this principle,
which Dr. Brown professes to have discovered as regards scarlatina, be the
correct one, can only be determined after extensive and frequently repeated
experiments.

Finally, to all the evidence adduced by Dr. Brown in favour of the pre-
servative effects of acetic acid upon the blood, it is proper to oppose the testi-
mony of our best American authority, as to its injurious effects in large and
long-continued doses. Dr. Wood, in his Therapeutics, says that, thus ad-
ministered, besides producing gastric and intestinal irritation, "it lowers the
organic functions of the system generally, impairing nutrition, depraving the
blood, producing anaemia and emaciation, and ultimately, it is said, inducing
a condition analogous to the scorbutic." The same writer refers to its liability
to develop the tubercular diathesis, when taken habitually, as it sometimes is,
with a view to obviate fatness. Whether, and to what extent, Dr. Brown's
use of the article should be considered toxical, it would be difficult to say ;
but probably the diluted state in which it is given, and the comparatively
short time that it is administered, will save it from being so regarded, except
in so far as many of our best remedies are poisons, in over-doses.

Art. III. — Cases of Partio- General Paralysis, or the Paralysis of the Insane.
By Pliny Earle, M. D.

In previous issues of the American Journal of the Medical Sciences, I
published two series of cases of that peculiar disease termed, by the French
physicians, Paralysie generale, and by the English and the Americans, para-
lysis of the insane, but for which I ventured to suggest the name, partio-
general paralysis.

Those cases included all the distinctive characteristics of the disease, and
the number of autopsies was sufficient to furnish a pretty clear idea of its

1857.]

Earle, Partio- General Paralysis.

cerebral pathology. Most of the cases, a report of which it is proposed' to
include in this article, present peculiarities, or exceptional characteristics,
which render them worthy of preservation. In the one first presented, the
disease ran its course so rapidly that the patient was exhausted before the
extreme symptoms of paralysis had appeared.

Case I. — Mr. was born in the interior of the State of New York.

He was of medium stature ; his hair was light-brown, his eyes blue, and his
temperament bilious-nervous.

He learned the business of printing, and worked at it for some years. His
intellect was above mediocrity, and his acquirements became such, that at
length, and during a term of several years, he was an assistant editor of a
newspaper in the city of New York.

In business, he was industrious and persevering; in habits, generally es-
teemed correct, although, from early life, it is supposed that he gave a pretty
free rein to the venereal propensity. He also drank wine, but perhaps never
to intoxication. He was married, and had several children. It is said that
his parents were both " eccentric," if not insane.

In the summer of 1847, it was observed that he had become unnaturally
irritable. This disposition increased upon him through the ensuing autumn
and winter, and, in the spring, there were some evident symptoms of insanity.
He, however, continued in his business until about the 1st of May, when the
disease prevented the further performance of his duties. On the 10th of
May, at the age of forty-two years, he was brought to the Bloomingdale
Asylum.

Condition on admission. — He is restless, excited, and incessantly talking,
if any one be present. Countenance animated j pupils contracted, unequal
— that of the right eye the smallest ; tongue moist, pallid, smooth, and very
slightly coated ; pulse considerably accelerated. No abnormal sound of the
heart.

May \lth. He occupies one of the best rooms, and, if alone, is quiet.
He says the Common Council will give this Asylum to him. He will
have four hundred mechanics here, and will raise vegetables enough to sup-
ply the city. He will want two or three clerks, and three secretaries. He
will give ten thousand dollars to stay three weeks and carry out his plans ;
or he will buy the place in less than a week, pay one hundred and fifty thou-
sand dollars for it, which will not be more than a cent to him, will have all
luxuries, and supply all the other patients with them, and will cure all the
patients by a special course of treatment.

He has a very slight impediment in his speech. In the midst of conver-
sation, he stops to whistle or to sing.

13th. He says he is the cream of American patriotism, and that Grod' has
revealed to him all the events of the last six weeks. He is restless, loqua-
cious, petulant; sheds tears, and asks if Washington is not here.

Ikth. He mentions the names of several attendants and patients, claims
them as his illegitimate brothers, and offers each of them " a carriage, horses,
and twenty thousand dollars, to start upon." Says that he shall be the next
President of the United States, and that the Supreme came down last night,
and rested on the window-sash, and is still in that cloud (pointing upwards
through the window), ready to come down at his bidding.

lbth. He asserted that he is the "Duke of Gloucester, and entitled to the
throne of England, of which Yictoria is not the legal possessor." A few

Earle, Partio- General Paralym

[July

minutes afterwards, he said he was President of the Uuited States and King
of England ; that his legs are iron, and that he wound up the sun yesterday.

lQth. He calls one of his fellow-patients the Pope, and to several others
gives the titles of some of the English nobility.

20th. His excitement has gradually increased from the time of admission.
Having become very boisterous, by both day and night, and having begun to
destroy furniture and clothing, he was now removed to the ward for violent
patients.

21st. He declares that he is the son of the King of the world ; that he
was in the Crusades ; that the writings of Shakspeare and Scott are merely
a record of his life ; and that he had a conversation with the Black Prince
night before last.

22d. Says he killed Abel, in the garden ; that Eve was his mother ; that
all the people in the world are descended from him ; and that the Dutch
Queen had such an affection for him that it made a tumour grow on his right
side. He is much excited, very noisy at night, and destroys clothing.

23(7. On entering his room, I said : " You are noisy !" " I've a right to
be," he answered. " I'm the god of thunder !" His tongue, as usual, is
covered with a thin, white, strongly adherent, pasty fur; bowels habitually
costive ; right pupil smallest — both contracted ; pulse 96, regular ; sounds of
heart normal; general sensation obtuse. He has emaciated constantly since
admission.

2Qth. He tore his bed to tatters " to find his cattle;" says he can jump
over the house, but is so large he cannot go through the door; tells the
physician that he can hold him on his little finger, and could sustain the
weight of the world if he had a foothold.

Neither his mental nor physical symptoms changed during the early part
of June. On the 19th, his scalp, forehead, and right arm, were much tume-
fied and ecchymosed, as if beaten against the wall. Being asked how it was
done, he laughed, and said: " Jesus Christ did it." Towards the end of the
month, and in the early part of July, he became more emaciated and feeble ;
his excitement was less constant, but occasionally, even in the latter part of
J uly, he was very turbulent. At the close of the month he was nearly ex-
hausted, all the worst symptoms, both mental and physical, above mentioned,
continuing. Almost the last words he uttered were an assertion that he was
one of the men mentioned in the Old Testament. Died, August 2d, 1848.

Treatment. — Purgatives, alteratives, and tonics. A seton was inserted in
the back of the neck on the 23d of May, and continued until his death. The
discharge from it was never copious. Regardless of all medication, the dis-
ease regularly proceeded towards its fatal termination.

Autopsy, sixteen hours after death. — Pericranium pretty strongly attached
to the skull, and but little blood in the vessels. Cranium adheres more than
normally strong to the dura mater. It is of ordinary thickness, and not un-
usually hard. The dura mater adheres to the subjacent membranes on the
anterior lobes, and for three inches over the vertex, on the border of each
hemisphere, beside the longitudinal sinus. The latter attachments can be
separated by dissection alone. The whole brain, when removed from its
cavity, appears unnaturally soft or flaccid, and its weight, when laid upon its
base, partially tears asunder the corpus callosum. The arachnoid is thick-
ened, semi-opaque, and strongly adherent to the pia mater upon the whole
surface of the cerebrum, except the base, where it is normal. The pia mater
adheres so strongly to the cortical substance, that, on removal, it brings off
small patches of it. Bloodvessels not remarkably injected. The cortical

1857.]

Earle, Partio- General Paralysis.

matter is of normal colour, but is decidedly softened. The brain being cut,
the surface of the medulla is interspersed with some bloody points, but they
are not numerous. The corpora striata, and the medullary matter around them,
are thought to be somewhat softened — the most so in the right hemisphere.
The fornix is very soft. The pineal gland contains very little sabulous
matter. There are filamentous adhesions between proximate surfaces in the
fourth ventricle, and at the base of the brain. One ounce of serum in the
ventricles and at the base. Cerebellum thought to be somewhat softened.
Its investing arachnoid apparently normal.

Considering the protracted course of the next case, and the comparatively
extreme degree of the paralysis of the voluntary muscles, it is remarkable
that the functions of the digestive organs were so little impaired, and that the
patient was exempted from those sloughing ulcerations which are one of the
most striking characteristics of the disease in its severer forms.

Case II. — Mr. was a native of the State of New York. He was

tall in stature, his hair black, eyes blue, temperament sanguine-bilious, the
bilious greatly predominating, constitution mediocre. His intellectual facul-
ties were fair, and he received a good English education. Being devoted to
mercantile pursuits, he emigrated to a southern State, at the age of between
25 and 30 years, established himself in business and was sufficiently success-
ful. He was never married. It was said that his habits were correct, but
by persons who had no intimate knowledge of his course of life. His mother
was eccentric, but it was asserted that he inherited no predisposition to men-
tal disorder. At the age of 35 years he had scarlatina; and at the age of
43, what is described as a " slight attack" of paralysis. He lost his property
and became excited with political affairs, but whether prior or subsequently
to the commencement of insanity, could not be accurately ascertained.

Having become insane, he was brought by sea to New York. On board
the vessel he was so violent that he was most of the time kept in a strait-
jacket.

On the 18th of March, 1848, at the age of 45 years, he was taken, as a
patient, to the Bloomingdale Asylum. He was then emaciated, his skin sal-
low; the tongue furred and pasty; bowels costive; pupils unequal, the left
being the larger; speech imperfect and hesitating; gait faltering. He ap-
peared bewildered, thought he was in Savannah; said he saw an angel on the
previous night; would begin to speak, and, forgetting the idea, run to an-
other subject.

He slept but little, at night, during the first few weeks after admission;
but he could not bear opiates. One morning his forehead was severely
bruised, probably, as has occurred in other cases of the kind, by running
against the walls. On being asked how it was done, he said, " The raft slid
into the river and many people were killed, but the ladies walked across the
plank of the steamboat and were saved." On the 14th of April he said that
he was in a southern city, and that on the previous night they " stuck him
into a rotunda to sleep." A copy of a New York newspaper being handed to
him, he appeared much astonished and remarked that " it must have come
by telegraph." General sensation was then very obtuse. On the 16th, he
said that in the night he saw five or six hundred little soldiers, beautifully
dressed, and on horseback; they were not larger than his forefinger, but they
" fought the Bostonians courageously, like tigers." His bed being wet and
emitting a strong odour of urine, he was asked the cause of it; and answered

Earle; Partid- General Paralysis.

[July

that some person opened his window, and a shower coming up, it rained upon
him — hut it was warm rain. The night was clear. On the 20th, his appe-
tite was good, and he was gaining flesh and improving in general health. He
said he had some barrels of the best wine in the world ; and, assuming a very
earnest, business-like manner, requested to be let out into Broadway, as he
was going to the banks and was afraid he should be too late.

In the summer he took LugoPs solution of iodine; and a "seton, which was
introduced on the 4th of April, caused a free discharge. He gained flesh,
and his general health was good. His mental condition varied, but was at no
time much, if any, better than at the time of his admission. He had but
little memory of recent events. Soon after a visit from his mother, he said
it was more than a year since he had seen her. In the early part of August
it was perceived that he had lost the sense of taste. He ate all kinds of food
with equal relish. In the early part of September, his feet were cedematous
for a few days.

On the 17th of November his pulse was 76, regular; pupils unequal, the
left being the larger; appetite voracious; face and feet cedematous; gait un-
stable. He walked with his feet far apart, like an infant; the grip of the
hand and the strength of the arm were feeble; speech considerably impeded,
but less so than at some former times. At this time, he occasionally tore his
bedclothes and upset the furniture in the room. On the night of the 29th
of November, he thought the earth was sinking, and, in order to save him-
self, he turned his bedstead up, upon the side, and seated himself astride it.
He said he was thus enabled, by using his utmost exertions, to save himself
from being engulfed. His speech was now much more impaired than at any
previous time. G-eneral sensation was nearly null, but existed to a greater
extent upon the legs than upon the superior portions of the body. His feet
and hands were somewhat cedematous. He asserted that he could run twenty-
five miles in an hour, or walk twenty miles, and that he owned six hundred
acres of land at the South and one hundred acres in Harlem, occupying the
latter as a barber's shop. Being requested to write a letter to his mother, he
sat down, and, after much labour, hesitation, and alteration of orthography,
produced a document, of which the following is a copy : —

" Mrs. Deear Motherr

Vder as this 29th Jurly

b — o gond to

$18. S. DOOCCKET."

The signature bears no resemblance to the name of the patient, except
that the initial letters of the former are the first two of the three which belong
to the latter.

There was no material change in his general condition at the time I left
the asylum, in May, 1849. Neither was there, as I am informed by my suc-
cessor, Dr. Nichols, throughout that year. During the whole of his residence
in the asylum he never recognized, as an acquaintance, any person except his
mother. During the last six months of his life he did not know even her.
In the early part of 1850, the power of the voluntary muscles visibly dimi-
nished, but most rapidly in the lower extremities. For six months before his
death he could not walk without aid. His digestive functions remained but
slightly impaired until the 5th of August, 1850, when he was attacked with
diarrhoea and died on the following day. No autopsy.

The third case is exceptional, so far as my observation is concerned, in the
striking similarity of its earlier symptoms to those of mania-d-potH. The

1857.]

Earle, Partio- General Paralysis.

disease was rapid in its course, and all its other characteristics would probably
have soon assumed their worst form had not the patient been carried off in
an attack of cerebral congestion.

Case III. — C. was a native of Ireland. His constitution was strong,

frame robust, stature medium, hair sandy, eyes gray, temperament sanguine,
intellect mediocre, education common. At the age of about 22 he emigrated
to America, settled in the city of New York, and established himself as a
retailer of liquors. He was subsequently married. He afterwards became
addicted to the daily use of alcoholic drinks, though not frequently to intoxi-
cation.

In September, 1846, when he was at the age of 28 years, he lost a favour-
ite child3 and his friends say that his insanity appeared immediately after-
wards. He was subjected to no medical treatment. For four weeks he
gradually grew worse : was restless and talkative, and indulged in extravagant
schemes of business, made imprudent purchases, and wandered about the
city, apparently without any definite object. At length, having determined
to go to Ireland, he went to a wharf, jumped into a boat, and rowed himself
out into the river. His determination then changing, he leaped into the water
and swam to the shore.

A day or two after this occurrence, and on the 16th of October, he was
brought to the Bloomingdale Asylum. His friends asserted that he inherited
no predisposition to mental disorder, and had always enjoyed good bodily
health.

During the first three days after his admission, he had all the symptoms of
a person labouring under a severe attack of delirium tremens.

He was excited, sleepless, turbulent; had hallucinations of vision, and
would keep no clothing upon himself, excepting a blanket thrown over his
head, or wrapped about his body. His tongue was tremulous, his pulse
rapid.

After catharsis with cal. et jal. followed by compound cathartic pills, he
took mass, ex hydrarg. gr. ij. t. d. and, subsequently, a portion of pulvis pur-
gans. On the 23d, he was so much improved that he was permitted to be in
the hall and to go out of doors; and, on the 24th, he began to take a tonic
vegetable infusion. He rapidly gained strength, and on the 29th the medi-
cine was stopped. During this period there was a partial bewilderment in
his aspect and manner. He was careless of his personal appearance, at times
tore his clothing, and was otherwise mischievous. His appetite was now
good. He generally ate voraciously, and required occasional purgatives.
This was the only medical treatment to which he was subjected, with the
exception that, a few days before his discharge, he took Fowler's solution gtt.
v. t. d.

November 10. For several days past he has uttered the most extravagant
ideas. He now says he owns the asylum premises, and is worth two hundred
thousand billions of dollars. He also declares that he is the head of the
church throughout the world, and is going to turn the earth into a paradise,
and manage it all himself.

11th. He went to the school-room and wrote a letter to his wife, from which
the following extracts are made : —

" I am at the reading school and am one hundred times as smat as any of them
they they are the greatest dunces in Eternity I shall commence travelling next
week Please God and the first place I will go to is to my native own green Isle"
* * * "I would not trust the word no but the Oath of G. and 0. I wd not

Earle, Parilo- General Paralysis.

Trust them in an Empty room or a room full of Mill stones I am tak as many
friends as go with me By their Paying Expences it wud not not mak much of a
difference I shl have High life all over the continet and all the Corners in the
World which I will make a Parridise of all the world and Have shepherds to
take care of them so that has Plenty

Resp ful

Head of the C. Church
all over the world

12i7i. The pupils are unequal, the right being the larger. There is an
evident stammering in his speech, and general sensation is so obtuse that he
can barely feel the most severe pinch.

He says he is worth ten times as much as John Jacob Astor. Being seen
to make some strange gesticulations, he was asked what he was doing, and
answered that he was blowing himself up; that he could blow himself so
large that he would be thirty feet in height, or reduce himself to the size of
twopence. On being requested to blow himself up, he put the end of the
forefinger of each hand into the ear of the corresponding side, elevated his
head, rolled his eyeballs as far upwards as possible, compressed his mouth,
puffed up his cheeks with air, stretched himself upwards, standing upon tip-
toe, and thus exerted himself until his body was in a general tremor. Upon
being told that that was enough, he said, " Oh, that is nothing ; I only went
up to nine feet."

IQth. He is endeavouring, with but little success, to sing; says he hears
and sees music throughout his body, and can sing better than any man at the
Italian opera. He asked for writing materials, for the purpose of w corre-
sponding with all the different governments on the subject of converting the
world into a paradise." Being permitted in the afternoon to go to the school,
he wrote a long letter to his wife. It was so badly written as to be almost
illegible, and closed with a postscript consisting of two verses of pretended
poetry, but, so far as it could be deciphered, contained no rhyme and but little
reason. From this time his delusions continued unchanged.

23(7. Sphincter of the bladder apparently paralyzed. He says he can swell
to the height of more than a hundred feet. He is very noisy at night; chews
and swallows pieces of woollen rags, picks his clothes to pieces in the daytime,
and empties the straw from his bed at night.

2bth. He shuts his eyes, and says he sees "gold and all the brilliants in
their shape and lustre manufactured ;" says he weighs five hundred pounds,
can run thirty miles in an hour, and walk twenty. He frequently " blows
himself up;" attempts to sing, talks of his wealth and of his proposed con-
version of the world into a paradise. He exhibits little or no interest in his
relatives and friends.

On the 26th he fell into a state of coma, with very slight spasms of the
limbs of the right side. This resisted the usual remedies for more than twelve
hours, when he partially revived. He continued in bed, rarely speaking, and
with but imperfect use of the right arm and leg, until the 29th, when he was
removed from the asylum, and died at home on the following day.

No autopsy.

The subjoined is the most remarkable case of the kind that has ever fallen
under my observation. It is the only case of recovery from the partio-general
paralysis that I have ever known, and the second of which I have ever heard

1857.]

Earle; Pari 'io- General Paralysis.

as occurring in this country. Mr. Calmeil, who first minutely described the
disease, and who had for more than twenty years been connected with the
hospital for the insane at Charenton, near Paris, where hundreds, perhaps
thousands, of cases had been treated by him, informed me, in 1849, that he
had never known a case of complete recovery. He had had patients who
improved sufficiently to return to their homes, and, in some instances, to pur-
sue their occupations, but in every one of them the disease had resumed its
course.

Case IV. — Mr. was a native and resident of one of the interior coun-
ties of the State of New York. He was of medium stature, with brown hair,
gray eyes, and lymphatico-nervo-sanguine temperament. His constitution was
strong; his intellect above mediocrity. After pursuing a classical course of
study, he read and practised law, and became eminent in his profession. He
was married at the age of 34 years. Although not intemperate, according to
the common acceptation of the term, yet it was said that he "liked good living,
and indulged freely in the luxuries of the table/' One of his paternal uncles
was insane, and a maternal aunt was affected with melancholia.

In August, 1847, he was much afflicted by the death of a favourite child ;
and in September, having involved himself in pecuniary difficulties, he became
melancholy. In the early part of 1848 he had an epileptiform fit, which was
followed by another upon the same day, and, subsequently, by several others.
It was said, however, by his friends, that previously to this his speech had
become defective, and the muscles of his arms so much impaired in their
action that he was unable to write. His disease continued gradually but slowly
to progress, and for some time he was under the care of the local physicians.
On the 30th of July, 1848, at the age of 42 years, he was received into the
Bloomingdale Asylum.

At the time of admission he was much excited, constantly in motion, walk-
ing to and fro, talking incessantly and incoherently, mostly upon pecuniary
matters. He wanted to go to Wall Street, where he said he would purchase
$35,000 worth of railroad stock, and make a great speculation. He spoke
rapidly, but frequently dropped a syllable, and sometimes hesitated, from in-
ability to utter a word. The pupils were contracted, but of equal size; tongue
furred j pulse somewhat accelerated. After the administration of a dose of
pulvis purgans, he was put upon the use of twenty drops of antimonial wine,
with ten drops of the tincture of digitalis, three times daily.

31st. He is still much excited, shouting that he wishes to get out of the
house and go to W all Street. His speech is more imperfect than it was yes-
terday. No evacuation of the bowels. R. — Cal. et jal. aa grs. x.

August 1. There having been but a slight alvine movement, another por-
tion of pulvis purgans was administered. This produced free catharsis, and
his excitement was considerably subdued.

Qth. The pupil of his left eye is larger than that of the right, and there is
an evident partial paralysis of all his limbs.

11th. His excitement has almost entirely subsided, and the paralysis has so
far increased that he cannot walk without support. Stop the vin. ant. and
tinct. digital., and give a tonic vegetable infusion three times daily.

14$. His ideas of wealth, of station, and of power have been constantly
increasing since his admission. He now says that he began business with a
borrowed capital of three hundred dollars, and from that has accumulated a
fortune of five millions ; that in the town of Oswego he has one hundred and

Earle, Partio- General Parayhis.

[July

fifty mills, each containing five runs of stone, and the whole turning out twenty-
five thousand barrels of flour each week ; that a million of dollars has been
cleared by this operation ; that he has seven ships at sea, four of them on
whaling voyages, two bound to China for cargoes of tea, and one to the Medi-
terranean for fruit ; that he has purchased the whole of the United States,
except New York and Philadelphia, together with the wheat lands in Canada,
and the whole of Mexico, for all of which he paid but one million of dollars;
that he owns two coal-mines, one in Virginia and the other in Mexico, all the
copper-mines in Wisconsin, one gold-mine in Africa, all of those in Mexico,
as well as all other mines of gold and of iron, and that his income from each
of these mines is seventy thousand dollars in three weeks; that among the
rest of his property are — 1, the Bank of Milwaukee, with a capital of three
hundred thousand dollars; 2, three hundred thousand dollars invested at twelve
per cent, interest in New York ; 3, stock to the value of five and a half mil-
lions in the Hudson River Railroad; and 4, a factory in one of the towns upon
the Hudson River ; and that he is about to establish a bank in New York,
with a capital of two millions of dollars.

He asserts that he is a J udge of the Supreme Court of the State of New
York, and a member elect of the next Congress; that he is to be appointed
minister to England; and that he shall be elected as the next Governor of
the State, and the next President of the United States after General Taylor.
He proposes to start, to-morrow, on a tour to the Catskill Mountain House,
the Thousand Islands, Quebec, Montreal, Oswego, Falls of Niagara, Ohio,
Washington, Florida, Mexico, and Buenos Ayres, returning by the way of
Mexico, Mississippi, Illinois, and Oregon. This journey, he thinks, will
occupy his time for four weeks. He intends, after it is completed, to start
for Europe, and spend two years in England, two in France, one in Switzer-
land, one in Germany, one in Sweden, three in Russia, one in Norway, one
in Turkey — in Constantinople — (" Con-con-stan-no-nople," as his impaired
enunciation makes it) and one week in Africa, making, in all, eighteen years.
He proposes to take his wife and children to Russia with him, in a steamer of
one thousand tons burthen, which he will have built expressly for the pur-
pose and named for himself and wife. He will freight it homeward with
English goods which will yield a profit of $100,000. On its second voyage,
he intends to return and to build twenty houses, at a cost of $10,000, each,
on one of the docks in New York.

17th. His general sensation is obtuse; his taste imperfect. A portion of
the sulphate of magnesia being prescribed for him, it was made into a strong
solution which he drank, saying that it was u first-rate Congress water."

21st. The paralysis has extended to the sphincters of the bladder and rec-
tum. The patient's speech is variable, being much more imperfect upon
some days than upon others. His memory of recent events is almost entirely
destroyed. He says that he has invited several guests, among whom are God
and Van Buren, to dinner ; and that one of his whaling vessels arrived yes-
terday with twelve hundred barrels of oil, upon which he will make a nett
profit of fifty thousands of dollars. On being informed of the recent de-
structive fire in Albany, he remarked that he did not " own any of the build-
ings which were burned, except the Eagle Hotel, the Mansion House, the
Townsend House, and the Odeon, which are all insured for their full value."
He added that he has " bought all the land of the burned district, and is
going to build it up with marble and that he will " immediately give one
hundred dollars to the sufferers, and fifty thousand dollars by and by."

There are many sores upon different parts of his body, some of them appa-

1857.]

Earle, Partio- General Paralysis.

rently having arisen without any external cause, and others the ulceration of
places upon which the skin was abraded in the course of his period of high
excitement. Attempting to write his name, his hand is unsteady, moving by
partial jerks; and although one or two of the letters are pretty accurately
made, others are very imperfect, several are entirely omitted, and there are
some unmeaning marks. It takes him probably five times as long to write
it as it did prior to this disease. On the second attempt he is somewhat more
successful, but his writing is no better than that of a child in his first essay
upon a connected fine-hand copy.

September 1. The left pupil is larger than the right; but both are con-
tracted.

Sd. He says he is worth ten millions of dollars; that the Lord came down
to him ; that he is now sixty-five years old, but the Lord will make him only
twenty-five.

bth. Besides his fanciful ideas of wealth, he now has many religious de-
lusions. He often calls himself a bishop, or a clergyman, and asserts that
he is going to preach in Trinity Church.

11 tli. He says that God is up in the room, on his throne, and is going to
preach to-day; asks us to go up and see him. A seton was, this day, in-
serted in the back of the neck.

ISth. He talked as follows: " I went up to God, one day, and said, * God,

what is the reason that and are in hell?' His answer was, 'They

are not in the right line of succession with the church.' ' Well/ says I,
' what does the devil do with them when they are first put in there V He
said they were first ground down with fire and red hot iron ; afterwards they
were ground down with spirits of turpentine and saltpetre. Don't you think
that will make them smart?" He then proceeded to give an account of his
wealth, and concluded by saying that he was the most eloquent lawyer in the
world.

21tli. His pulse is always rapid. It is now 124 per minute, small and
regular; pupils nearly equal, tongue slightly coated, bowels regular, the
sphincters under voluntary control, general sensation less obtuse than it
has been. He writes better than he did, and can stand alone, but cannot
walk without assistance. Being asked how much he was worth, he answered
" Nine hundred thousand dollars," hesitated a moment, and then added,
" No ; God says it is ten millions. I have made ten thousand four hundred
dollars while you have been sitting there ; and I own a million dollars' worth
of jewels." He then said that hey goes up to Heaven, to see his father,
and offered to take his mother up' with him.

The seton produced a considerable discharge throughout the month. The
tonic infusion was stopped in the early part of October, and followed, through
a large part of the month, by alterative doses of the bichloride of mercury.
Under this treatment the discharge from the seton almost entirely ceased,
most of the sores upon the body healed, and the appetite and digestion of
the patient continued to be pretty good. In the latter part of the month he
was attacked with diarrhoea which was subdued by opiates. All the charac-
teristic symptoms of the paralytic insanity varied from day to day, but, sub-
sequently to the 27th of September, the patient was not at any time better
than upon that day. The general character of his delusions remained un-
changed. At one time he enumerated the different offices of which he ima-
gined himself to be the acting incumbent. Among them were the presiden-
cies of several banks, insurance offices, and railroads; a number of bishoprics;
No. LXVIL— July 1857. 4

Earle, Partio- General Paralysis.

[July

offices under the national government, &c. &c. He made the aggregate sala-
ries $76,000 per annum.

On the 3d of November, 1848, the patient was removed from the Bloom-
ingdale Asylum to Dr. MacdonaloYs private institution, at Flushing. There,
after a residence of some time he began to amend, and at the end of a few
months was discharged, recovered. Dr. Macdonald died soon afterwards, and
I had no opportunity of conversing with him in regard to this very remarka-
ble case. I am informed, however, by Dr. Benjamin Ogden, that no special
treatment was pursued which was supposed to have effected a cure, but that
Dr. M. attributed the patient's recovery solely to an effort of Nature.

This gentleman is still living. He is in excellent health, both physical
and mental, and is engaged in an extensive and successful business.

In the following case, the symptoms, not only in its earlier periods, but
along its course, were such as to lead the experienced observer to the progno-
sis of paralysis ; and yet, although the progress of the disease was compara-
tively slow, and although some of the other most peculiar characteristics of
the partio-general paralysis were present, the paralysis itself never appeared.

Case V. — Mr. , a native of the interior of New York, was of medium

stature. He had brown hair, gray eyes, and bilious-nervous temperament,
the nervous greatly predominating. His talents were fair, and he received a
good common education. He was active, intelligent, and of mild disposition,
though excitable. His mother once had an attack of insanity. He entered
into business, and when quite young accumulated great wealth by speculating
in real estate during the years 1835 and 1836. This fortune, however, he
subsequently lost; and afterwards engaged in various kinds of business.
He was married and had children. In the winter of 1845-46 he came to the
city of New York, in the hope of finding employment. Soon after his arrival
his friends perceived that he was eccentric, wilful, and easily excited; more
than usually talkative ; self-complacent when speaking of his business capa-
city, and elated with great hopes for the future. These symptoms increased.
He began to make imprudent purchases; gave away his money, lost sleep,
and grew more and more excited until the 23d of February, 1846, when, at
the age of 36 years, he was brought to the Bloomingdale Asylum. His
friends stated that he had had a cough ever since the preceding summer.

State when admitted. — Emaciated, somewhat sallow ; pupils natural, tongue
slightly furred, bowels costive, pulse 110. He is restless, and very talkative,
but shows no disposition to be violent. He consents to remain, but thinks
that u placing a man, so well as he is, in a Lunatic Asylum, is one of the most
ridiculous farces ever imagined." His general conversation is quite rational,
and no attempt is made to elicit his exalted ideas. Before his friends leave,
however, he in great good humour takes some papers from his hat and re-
quests the Dr. to look at some poetry which he has this day been writing.
The paper contains six stanzas, the first three of which he says were written
by his favourite author, Mr. Tupper. The others are a parody upon them
composed by himself. After reading these lines, and hearing a history of his
case, I told his friends that I thought there was but little hope of his reco-
very.

February 24. R. — Blue mass gr. ij t. d., with an aloetic pill morning and
evening.

1857.]

Earle, Partio- General Paralysis.

March 1. Skin more natural and he looks less worn; tongue clean, appe-
tite and digestion good. Stop mass and pill. R. — Tinct. opii gtt. x t. d.

4th. Bears the opiate well; sleeps sufficiently. Increase tinct. opii.

Four days after admission he wrote a letter in reference to some mineral
lands to a gentleman in the northern part of the State, with whom he was
entirely unacquainted, requesting him to take men and teams to those lands,
procure one or two thousand barrels or boxes of all kinds of minerals and
send them to him in New York; stating furthermore, that if the said gentle-
man had not money euough to accomplish this object, he might draw upon
him. He then proceeds, by way of introducing himself to the stranger to
whom this letter is directed, to give a genealogical history of himself, and of
his wife. He says that if the minerals should prove to be rich and the lands
valuable, the county in which they are situated will become more populous.
" We will," says he, " put a bank at your place or in Peru, and it would be
a good place for a college for the north of this State, better calculated than
any in the State now ; for it might be used for the poor of the State, as
well as those who could handsomely pay. I speak of this as an inclination,
and not anything which would trouble me at all if it should not be worth
anything. And as to the sum to be paid to the noble man, the owner of the
farm, the soldier" of the great Revolution — why, I think I would not feel a
sigh to pay him $200 a year as long as he lives, without any interest at all,
if it would do him good, for I feel perfectly well off, and it would give me
much pleasure and contentment to do such a thing."

About the time of the date of the foregoing communication, after reading
the advertisements of several valuable houses that were to let in the city of
New York, he wrote to the owners, advising them to furnish the houses, as
they would then rent more profitably than if unfurnished, and made some
preliminary propositions in regard to hiring them. He subsequently wrote
the following letter : —

New York, March 20, 1846.

"To the Hon. Daniel Webster —

Sir : As a stranger, and having some business to have done at Washing-
ton, which I know to be of great importance to me, if not to our country. * * *
For three years I have known what I now write, yet have said nothing ; but
now, as the great and good men of both parties, conservatives, are all together,
I thought it of great importance; and it is this : That by using the bright sands
of the sea-coast, and the small, round, clean stones, or other hard matters, with
water-lime, you can make a road from here to the upper part of Oregon, in a
month, or less ; because water-lime, mixed with clean stone or glass, or any-
thing solid, will make a road much better than a railroad. So far in a month,
for instance* make it soft, and mix it clean, and throw it upon the ground as
far as you choose, and make it smooth, and, as soon as it is dry, it is, in my
opinion, harder than rock. And should the great men of our great demo-
cratic nation, now altogether to do right, believe surely, as I do, that, in one
day, I could, with that mixture, by the aid of good builders, make one hundred
ships a day. And now, suppose a ship was planned large enough to carry
thousands. Make it three feet thick and one hundred feet wide, and flat on
the bottom, having large places all along its side or bottom, to take it up if
necessary, and put down again. Well, it would require no ballast ; and round
the sides, from the bottom to the top, and, while it is soft, at the bottom fix a
keel, as low as profitable, that can at any time be hauled up for other purposes ;
such a ship, in my opinion, would draw but little. And, as far as war was
concerned, no common shot or ball could hurt anyone ; for it is a rock, smooth,
and the balls would slide under. Now, build as many as you please, in a month,
and put them together, and in two or three days they could reach England, and
everything upon the ocean could be taken without trouble, or anything else.

Earle, Partio- General Paralysis.

[July

The reason they would, in my opinion, go so fast, is that they could draw no
water, laying so flat, with a deep tiller, if it would be thought right, and with
engines of the screw to give them their power ; when they were wanted for
something else, it would be well to have the engine screw put in the bottom, so
that you could bring it within the ship, and have rollers under, which would
cross any land one hundred feet wide ; and make a railroad or road of hard
rock, and as fast as the stuff could be thrown out (I mean the sand-lime and
stone), the engine within would roll the rollers under the ship, and make the
road smooth and ready for use as soon as it was dry. And, before it was dry,
the same material would make a fence as high as would be necessary for any-
thing, by sticking them down when wet. Carriages, and everything, almost,
could be made, and will be, and buildings (safe from all fire) which now cost
so much, could be built by my patent for a little. Now, in my opinion, should
it be thought right, and above all question, in my opinion, England could be
made a State of this Union, and all Europe, and this hemisphere, and the whole
world, could easily be made one democratic kingdom. And now it is useless
for me to say more at present. I have wished to be secured in the Patent Office
for this matter for all time. All I have acted upon was a trial in digging a
hole for a post, and putting it in, and throwing in this material, and it became
stone. If such an arrangement could be made with our great men, say H. C,
C, the Secretary of State, Mr. A., and the best in Washington, why, I think,
without spilling any blood, an arrangement might be made with England, let-
ting them have their titles they now have, and making them and their great
men only as farces, our own great men to rule the world. I believe it was
Napoleon who said, before thirty years, that Europe would be democratic or
Russian. Now, I have been reading the great argument of Senator C. upon
our position with Great Britain — wonderfully correct, and, with one exception,
true. But he thinks to possess Mexico. It would cost millions. Why, it is
all wrong, for it would cost nothing to speak about. If it would be allowed
by our Union for a man to undertake the control of Mexico on his own account,
I am sure it could be done in a month, and could be done without asking a cent
from the country. I would begin a road with my mixture at Washington, via
New Orleans, and, at the same time, make arrangements with the wire tele-
graph to use it under ground instead of above, for the use of the Government.
There would be no hindrance from water or land in running such a road through
to Mexico, with such a fence that few could get over on each side of it, and no
guns could hurt or shatter the machine or ships. No blood would be spilt, but
all taken.

" Now, not to let it be known that ships and other things are made in this
way, it would be extremely necessary that the patent should be concealed, and
the ships covered with sheet iron, and call them iron ships. And as to Canada
and New Brunswick, it would be all the same, and I truly believe, if the ques-
tion was placed by the great men of this country at England, with our ships
in sight, that they would be satisfied to become part of our Government, and
in doing this without much trouble. It would insure unto the United States
the government of the whole world, making it democratic, or allowing the great
men of their country to join with ours in the government ; and it would be a
wonderful affair in respect to the religion of our Maker, for now the news of
the arrival from Europe is, that England is now in war at the East, and many
thousands have been killed lately ; and now is the time to put a stop to this
business. If I am right in my idea of the great and wonderful power our
Maker has given to this country, no argument, in my opinion, can be made
which can be a conviction of truth against this : that the United States should
do her most to gain the control of all they can, simply for the defence of their
own liberty, and the liberty of the whole world.

" I shall say no more at present, but, at all events, as soon as you get this
patented for me, and if you think I am wrong in my ideas of right, why keep
this a secret, and return it to me. I would have no man see it, if your opinion
is against it, as far as the Government is concerned.

Yours, respectfully, J1

"P. S. — Show this to Calhoun, and let me hear from you immediately."

1857.]

Earle, Partio- General Paralysis.

He wrote several letters to his wife. The following extracts are made from
one of them : —

" My happiest moment in life is now, I am well beyond all question, and
healthyer than I ever was before.

"I am so well that I have grown so strong and healthy that you would hardly
know me. I was measured yesterday and found myself at least 6 feet high with
boots on, my whole body looks as straight as it could be, and I cannot alter it.
I feel great in my power which has been given to me by my Maker, for there is
nothing I can not do in business and the following year will test the question."

* * * "I can write any thing, poetry, argument, and can sing as well as I
wish, and sing without knowing any thing, but with my ear, when I get through
this I will give you a happy song, of three or four verses which I think will be
suitable to the occasion. I have written to W upon country matters."

* * * " I can follow Tupper and I think I can do what he has done." * * *
"And now to' thro' off all nonsense I will write a few verses as I said I would

" Dear blessed sweet a dear Queen

Always so beautiful, as the sun shining
Upon the Earth which our Maker, green
Has given to you and to me, rising.
Upon this wonderful world beautifully seen
With our eyes beautifully shining, devising
Our word of the great truth, upon which we lean
Given by the Lamb of our Maker so, rising
Above the great world, by our Redeemers will,
That you and me, with holy thoughts, sighing
Away our delightful selves, so still
To our Redeemers ; wonderful rising
From death, to his everlasting good

Which wakes you dearest, and your loving .

Tn this beautiful world our hearts always good,
To Our Redeemer, which always will make us
Nature Nobleman, and quean with our
Dear blessed hearts in one hand, in one hand."

May 29. He has gained much flesh, his appetite, digestion, and general
health are very good, and there appears to be no indication for further medical
treatment.

From the time of his admission his restlessness and excitement have gra-
dually subsided. He is perfectly calm; and a stranger, in a short conversation
with him, might not perceive anything peculiar. To those around him, how-
ever, he frequently enlarges upon his magnificent schemes. He imagines that
he has more talent and skill in everything than any other man. In literature,
particularly, he believes no one to be his equal. He really plays skilfully at
cards and nine-pins, but is irritated at the least opposition.

After this he continued very slowly to improve, although he was subjected
to no further medical treatment. He had the liberty of the premises, upon
parole, and passed much of his time, during the summer, sitting or lying in
the shade, reading. He less and less frequently alluded to his extravagant
notions, and throughout most of the winter could not be induced either to
speak or write anything in reference to them. It was believed, however, that
he still secretly entertained some of them; and a degree of his self-compla-
cency was still exhibited. In the course of the winter he did considerable
writing for the officers of the institution, copying documents in a good, legible,
and firm hand.

Discharged, much improved, January 2, 1847. He went to his home.
About two months afterwards he called at the asylum, and appeared to be in
nearly the same condition as when he was discharged. He now attempted to

Earle, Partio- General Paralysis.

[July

obtain employment in the city, but his friends were obliged to send him again
to the country, as he was considered unfit for business. On the 20th of May,
1847, he was taken, handcuffed, to the Utica Asylum. For a time he was
excited and somewhat destructive. His ideas were exalted, and in the daytime
he was almost constantly in motion. He said he was going to be President of
the United States; that he owned the State of New York, and was going to
plough it all with a plough made of cement. He pretended to communicate
with his wife, and with the government, by telegraphic despatches. He thought
his food was poisoned, and at length refused to eat, so that it became necessary
to feed him. There was no evident defect in his speech or gait. In the au-
tumn he became more calm, and joined others in playing cards ; but even in
his best condition, if he was alone, he was constantly walking to and fro, rub-
bing his hands, and pretending to be making worlds.

After a few weeks he became more excited, and it was necessary to confine
him in a darkened room, and, at length, to his bed. Here, during the day,
he still talked almost incessantly — the making of worlds being a prevailing
topic. In the winter he had an attack of cerebral congestion, unaccompanied
by spasms. He roused from the immediate effects of this, but his mind was
much more impaired than before. Afterwards he had illusions and delusions
simulating those of delirium tremens. He imagined that he saw devils, and
struggled in encounters with them.

During the last few weeks of his life it became necessary to feed him, and
his bowels were moved only under the effect of powerful cathartics. He was
emaciated and ghastly, and his mental faculties almost entirely prostrate. He
died on the 2d of May, 1848.

The principal pathological appearances of the brain were as follows : Thick-
ening and opacity of the arachnoid pretty general; bloodvessels enlarged; pia
mater much injected; about four ounces of serum in the cranial cavity; sub-
stance of the brain generally softened.

In the autumn of 1848, I was requested, by Dr. H. D. Bulkley, to see a
patient then under his medical care at the New York Hospital, some of the
symptoms of whose case were very similar to those of the partio-general pa-
ralysis. The man died soon afterwards, and Dr. J. B. Arden, formerly one
of the house physicians of the hospital, furnished me with the following brief
history of the case : —

D , set. 33 years, resident of New York, boatman. About six

months ago the patient had a slight apoplectic attack, from which he so far
recovered as to be able to walk about in three or four weeks; but he has never
completely recovered the faculties of his mind. He has lost his memory and
the ability to recall the appropriate names of objects. He has not complete
control over his lower extremities ; walks with difficulty and unsteadiness ;
does not complain of pain in the head. The pupil of the left eye is much the
more dilated, but is slightly acted upon by light. General health good.

Nov. 2. Patient remains about the same; has no pains; walks about the
hall with the aid of a stick.

Dec. 4. Patient last night had an apoplectic attack, with tonic convulsions,
and in about six hours died.

Autopsy, eighteen hours after death. — On opening the cavity of the cranium,
there was found a large effusion of blood under the arachnoid membrane and
around the medulla oblongata. The lateral and fourth ventricles were filled

1857.] Packard, Cases treated in the Pennsylvania Hospital.

with fluid blood, in which were some coagula. There was no marked softening
of the brain. The right vertebral and the basilar arteries presented an appear-
ance resembling a varicose vein, or like a string of beads; in other words,
there was aneurism of these vessels. The basilar artery was in one point as
large as a pea, and this enlargement was situated under the pons Varolii.
Other organs healthy, as far as examined.

Art. IV. — Reports of Cases treated in the Pennsylvania Hospital. By John
H. Packard, M. D., late Resident Physician at the Pennsylvania Hospital.

Severe Injuries of the Head. — Perhaps there is no class of cases in surgery
which require the exercise of nicer discrimination or more careful judgment
to bring them to a successful issue, than severe injuries of the head, especially
those involving fracture of the skull. Rightly to decide when and how to
interfere, and when to maintain a "masterly inactivity," how long to deplete,
and when properly and safely to stimulate, must always be a matter of pecu-
liar nicety, as well as of weighty responsibility.

In the summer of 1855, several cases of this class were treated in the
Pennsylvania Hospital ; and it is hoped that the following notes of three of
them, taken at the time, may be of interest as bearing on the above-mentioned
points : —

Case I. Severe Compound Fracture of the Skull, with Compression of the
Brain; Recovery without Operation. — Alex. Macaulay, set. 22, a baker, of
somewhat dissipated habits, was admitted into the Hospital, July 3, 1855, at
7 J P. M.; having shortly before received a severe blow on the head with an
iron bar. On the right side of, and parallel to, the sagittal suture, there was
a lacerated wound of about four inches in length, and a corresponding fissure
in the bone ; no depression could be detected, and there had been but slight
hemorrhage.

He was entirely insensible, collapsed, and showed symptoms of compression
of the brain, such as stertor, and slow, laboured pulse. There was, however,
no paralysis, and his pupils were entirely natural.

His head was shaved, the wound closed by adhesive strips, and cold applied )
counter-irritation, by means of sinapisms and heaters to the legs and feet, was
also ordered..

Drs. Peace and Norris saw him about 10 P. M., but no operation seemed
called for.

July 4. Dr. Pancoast saw him, and ordered nitrous powders every 3 hours.
Calomel gr. v to be taken at once. P. M. The calomel purge not having acted,
I ordered it repeated, and followed by an injection.

bth. Pulse 44 in the minute, and full. Insensibility continuing. On
bleeding him to f^xij, his pulse rose to 60. Cups were afterwards applied to
the back of his neck, and 30 American leeches over each ear.

Qth. He showed symptoms of erysipelas, which soon involved the whole
scalp and face. This was treated with an ointment of zinci ox. ^ss ; axung. ^j.

Packard, Cases treated in the Pennsylvania Hospital.

9th. He is still stupid; matter discharging freely from an opening made
yesterday by Dr. Pancoast, just over the left ear; the original wound healing
up very kindly.

10t.h. Gums touched; stopped the powders, and began stimulating him by
beef essence, brandy and quinia.

After this, his mind gradually cleared up, and his general condition steadily
improved. An abscess formed over the angle of the jaw on the left side, but
this healed up well after the discharge of the matter, and

Aug. 9. He left the Hospital, cured.

Case II. Compound Fracture of the Skull; Recovery. — Gr. M. C, set. 25,
an American, of weak mind and dissipated habits, was kicked by a mule,
July 6, 1855, at about 9 o'clock P. M.

He was taken into a drug store, and thence, at 10? P. M., to the Hospital.

At this time he was unmanageable, screaming violently when touched, and
resisting any attempt at examination of his injuries. These consisted of a
lacerated wound about 2 inches long, just over the right superciliary ridge,
and an apparently considerable depression of the bone above. The hemor-
rhage was very slight. His restlessness and excitement were so great that he
had to be confined.

Dr. Peace saw him at about midnight, and etherized him with a view of
trephining; but being thus enabled to examine the injury more closely, he
did not consider the operation as called for. The wound was therefore closed
with strips of isinglass plaster, the patient's head shaved, and cold applied,
especially over the forehead. He continued very restless and excited through
the night, but slept a little towards morning, and became much calmer.

July 7. His condition was much the same, except that he continued calm
unless agitated by questions, or by noise in the room. His excitement
returned at once if he was at all disturbed. Dr. Pancoast saw him, and
ordered a diaphoretic mixture, and low diet.

8th. His pulse being slow and laboured, and his restless stupor continuing,
he was bled to f^xvj, with immediate alleviation of those symptoms.

9ih. Some fever. He was ordered nitrous powders. Diaphoretic mixture
also continued.

10th. His bowels having been confined a day or two, he was ordered calomel
gr. v, to be followed by a purgative enema.

His excitability began to pass into mere peevishness, and he gradually
acquired more command of his senses, begging to be allowed to smoke, &c.

The case progressed favourably until

17th. He became very uneasy again, so as to require confinement. Some
signs of erysipelas appeared on his face ; he was placed on the use of stimuli,
and the nitrous powders were stopped.

He was not so well ; stupor increased again ; pulse 86, feeble. In-
creased his stimulus.

20th. A good deal of stupor; erysipelas advancing.

21st. Stupor less; pulse 44, weak. He had slight diarrhoea, which was
not interfered with. Appetite bad; some apparent difficulty in swallowing.
Erysipelas fading.

22<i. He seemed much better; erysipelas nearly gone; diarrhoea much
less. Pulse about the same as yesterday ; appetite better. As he complained
of his feet and legs being cold, they were covered with woollen socks, sprinkled
on the inside with Cayenne pepper; a mustard poultice was also applied to the
nape of his neck. This application was repeated once or twice afterwards.

1857.] Packard, Cases treated in the Pennsylvania Hospital.

He continued to improve, and

26/A. His friends removed him, apparently quite well.
In January, 1856, I saw him in town, driving his sled, and perfectly well,
although of course weak minded, just as before his accident.

Case III. Concussion of the Brain. — The following case afforded as in-
teresting an instance as could well be imagined, of the gradual awakening of
the mental powers, stupefied by a severe concussion.

J. D., aet. 25, a designer, was admitted to the Hospital at 1 o'clock P. M.,
August 29, 1855. An hour or two before, he had fallen three stories through
a hatchway, striking first, the bystanders thought, upon his right hip.

He was entirely insensible, but restless and somewhat unmanageable. A
small puffy tumour existed near the crown of the head, but there was no
evidence of any fracture of the skull.

The right lower extremity, from the hip down, had been withered by
chronic disease, but presented no mark of recent injury.

He had been treated, before his admission, by cut cups to the nape of the
neck, and a hot mustard footbath. His pulse and skin were good ; his pupils,
though not entirely unaffected by the light, did not answer well to it. He
was ordered at once a hot mustard footbath, and a sinapism to the abdomen;
also an enema containing ol. terebinth, f^j, suspended in starch water. Hydr.
chlor. mit. gr. vj, were given internally ; to be followed by a purge.

8 P. M. No change in his condition ; his restlessness made it necessary to
confine him. 10 P. M. Bled him to f^x. Ordered sinapisms, alternately
applied to the calves and soles.

Aug. 30, 8 A. M. Bowels not yet moved. Ordered ol. tiglii gtt. ij. 11 \
A. M. Dr. Pancoast ordered him an enema of assafoetida 5j> suspended in a
pint of water; a blister to the nape of the neck, and liq. ammon. acet., aq.
camphorae, aa f3ij, every 2 hours. 10 P. M. Ordered the assafoetida enema
repeated. At this time he was apparently completely unconscious, but noisy;
crying out, but not talking.

31s£. Counter-irritation still kept up. Dr. Pancoast ordered a pill of gr. \
Clutterbuck's elaterium ; this opened his bowels well. As he had taken no
food of any account since his admission, he was ordered beef essence. P. M.
His pupils answer to the light.

Sept. 2. He began to articulate a little.

3c?. Ordered pil. cath. co. no. ii; a hot mustard footbath at noon, and
again at bedtime.

\.th. The same to be repeated, with the addition of liq. ammon. acet. fjfss,
every 2 hours, and an enema of assafoetida, as before, at bedtime.

Qth. His mouth being sore, he was ordered an astringent wash. His mind
seems a little clearer, and his appetite good, but he has no consciousness, of
his passages. He takes up his cup of gruel, and drinks, and then after trying
to remember what to do with the cup, he drops it on the floor.

7th. 8 P. M. So much cerebral excitement that I bled him to about f^xvj.
Ordered an enema containing 3j of assafoetida to f^iv of water.

8th. Excitement much less. His mind acts very slowly and feebly. If
asked a question, he tries to answer, but slowly ; and he often has great diffi-
culty in finding the word he wants. Ordered hydr. chlor. mit. gr. ij, potassse
nitr. gr. v, t. d.

9th. He cries out " Oh dear !" a great deal; has done so ever since he began
to talk, on the 2d. When I asked him why he said that, he said "because
he could not think of anything else to say."

Packard, Cases treated in the Pennsylvania Hospital. [July

10 th. Pulse 72, skin natural, appetite good. His pupils, when exposed to
the light, first contract, and afterwards dilate. He does not know where he is,
though more sensible. Powders stopped.

IQth. He has grown much more rational, but his passages are still in-
voluntary.

18^. He was for the first time conscious of his evacuations. He got up
during the day, but it caused him some headache in the evening.

After this he steadily improved, still however showing signs of mental
weakness, and sometimes slight aberration. Thus he would say positively
that he had had no breakfast, when he had just finished a very hearty one.

Oct. 4. He was discharged as cured, though still liable to occasional slight
confusion in his ideas.

I saw him in the street, April, 1857; he was looking very well, and seemed
perfectly to have recovered the use of his mind.

Case IV. — Secondary Hemorrhage occurring fifty-six days after Gunshot
Wound of the Thigh; Amputation of Leg; Recovery. — Samuel Kempner, set.
21, a boatman, was admitted into the Pennsylvania Hospital, December 12,
1855, at 4 P. M.; having, at 11 A. M. of the same day, received a pistol-ball
in his right thigh. He walked into the hospital, apparently without much
difficulty.

A small round orifice, with ragged edges, and surrounded by slight inflam-
matory redness, existed on the inner surface of the thigh, about three inches
above the joint; a probe, introduced into it, passed upwards and outwards
about two inches, but no ball could be felt.

He was bathed and put to bed ; wound dressed with a flaxseed poultice.

Dec. 13. Discovered an ulcer the size of a ten-cent piece, apparently simple
in its character, on his penis ; he says he has had it for four weeks ; has
dressed it with burnt alum. This was well cauterized with nitrate of silver,
and afterwards dressed with warm water. P. M. Some fever ; ordered gr. x
of Dover's powder; ol. ricini §j, in the morning.

15^. Still some fever. Much more swelling, and some redness, around
the wound. Suppuration not yet free. P. M. R. — Liq. ammon. acet. f^ss,
every two hours.

18f&. Some little bleeding from the wound. Applied liq. plumbi subac.
dilut.

19th. Whole thigh somewhat swollen.

20th. Swelling somewhat less. Applied a poultice 8 by 10 inches over
the wound ; lead-water above.

23d. Greneral condition good. Discharge from wound free, dark-coloured,
and fetid. Posterior part of thigh much indurated. Some cough ; ordered
syr. scillae f3j every two hours.

2Qth. Yesterday and to-day his thigh has been less swollen, and the dis-
charge has been healthier. His knee has become bent and stiffened by lying
in the same position so long; but he can extend it better to-day than he could
a few days ago. The sore on the penis has healed up.

Jan. 3, 1856. Some fever. A hard, pointed swelling appears to have
formed on the back of the thigh, at about the same level as the original
wound. The discharge from this latter is very small. Ordered ol. ricini ^j;
gr. x of Dover's powder at bedtime.

bth. Fever moderated. Swelling and tension quite marked. Fluctuation
being distinct, I made an incision, letting out a large quantity of matter; a
poultice was then applied. P. M. The discharge having diminished, I ordered
gr. x of Dover's powder at bedtime.

1857.] Packard, Cases treated in the Pennsylvania Hospital.

12th. He has had a large poultice to the thigh for several days; Very
little discharge. Yesterday and to-day he has been feverish. Ordered at
"bedtime gr. x of Dover's powder, and a diaphoretic mixture.

lAth. For several days he has had a good deal of pain in the original wound,
which discharges a thin, yellow, ropy liquid, like synovia; that from the open-
ing at the back of the thigh is thick and healthy, but not copious.

l§th. A small spot of fluctuation existing near the last orifice, an opening
was made into it and the intermediate skin divided so as to lay them into one.

19th. There is a good deal of induration at the back of the thigh. He
complains of cramps and numbness in the foot. His knee is a good deal
flexed, and on straightening it a considerable discharge is pressed out of the
openings.

No important changes in his condition occurred after this till

Feb. 3. An attempt was made yesterday to bring the knee into a straighter
position by the use of a good deal of gentle force, and afterwards putting the
limb on a double inclined plane. During this attempt he said he felt some-
thing give way in the thigh.

To-day he feels weak and feverish, and was ordered nitrous powders.

P. M. Just after my evening visit he was reported to me to be bleeding.
I hurried to him, and found a strong arterial jetting from the wound at the
back of the thigh ; he was quite faint. The hemorrhage was controlled by
pressure until a tourniquet could be applied. Some two hours later there was
more bleeding, checked by the attendant screwing up the tourniquet. Dr.
Peace saw him at about 11 P.M.; applied a horseshoe tourniquet, and
ordered anodynes.

Qth, 7 A. M. Slept none during the night. Has pains and cramps occasion-
ally. The lower part of the thigh is much swelled, and a clot of blood fills
and is nearly pushed out of the wound, from which slight oozing has occurred.
His face and lips are very pale, and he feels very weak. Ordered a wine-
glassful of brandy and water.

10 J A. M. A consultation having been called, and ligature of the femoral
artery decided on, this operation was performed by Dr. Peace in the usual
way. The vessel was very small and its pulsations were so feeble as not to
aid in finding it. Brandy had to be freely administered before and during the
operation.

After this, free suppuration being established again from the back of the
thigh and the wound made in ligating the artery healing kindly, all went on
well until

15th. Hemorrhage occurred again from the back of the thigh to the amount
of about f^x, but was checked as soon as discovered.

16^/t. A consultation was held, and it was decided to attempt to secure the
vessel at the wounded part. Accordingly, the patient being placed on his face
on the table and a tourniquet loosely applied (pressure being made on the
artery above by the fingers), the wound was enlarged to about six inches, and
all the clot turned out. After some search, the upper end of the popliteal
artery (the distal portion of the wounded femoral) was found and tied. The
cardiac end of the femoral was next secured by scraping away a mass of par-
tially organized clot which surrounded it. (During this part of the operation,
the ball was found flattened against the bone, and with some calcareous de-
posit upon it.) These two ligatures were tightened ; a third was placed on
another vessel in the wound. The ligatures came away about the ninth or
tenth day. Some discharge was kept up from the wound for a good while
after.

Pierson, Statistics of Obstetrical Cases.

[July

Much blood was lost and free stimulation called for during the operation,
and when removed to his bed the patient was a good deal prostrated; he,
however, slowly reacted, and under a course of active and steady stimulation
and nutritious diet did very well.

20th. Wounds doing well. Pulse 124, and pretty strong. Some discolo-
ration in the foot, especially over the outer malleolus, where much of the
pressure has fallen during his confinement to bed. Sensibility impaired on
the anterior and under part of the foot.

The ligature came away about the eighth day.

This discoloration and loss of sensibility became more and more marked
until the whole foot and leg passed into the condition of dry gangrene ; the
fibula and several bones of the tarsus being laid quite bare in the course of
this process. His general condition remained pretty good, but of course he
required a supporting treatment.

July 16. The line of demarcation being clearly formed, and the patient's
condition good, Dr. Peace amputated the leg just below the knee. Ether was
given, and the operation was done by the circular method; the arteries were
very small, only five or six requiring ligature ; one, in the substance of the
popliteal nerve, bled quite freely and was tied.

After this he had not a single bad symptom, and, on August 21, he was
discharged cured, having been 253 days under treatment.

I have been unable to find any case reported in which secondary hemor-
rhage occurred later than the thirtieth day ; and the subject is only mentioned
in a cursory manner in most works on surgery. The above case may, there-
fore, be of interest and practical benefit, as illustrating the impossibility of
laying down any precise limits to the period of danger from hemorrhage, and
the necessity of constant watchfulness and attention to the processes going on
in each particular case.

Art. V. — Statistics of Obstetrical Cases. By Daniel Pierson, M. D.,
Augusta, 111. (Prepared for, and read before the Hancock Co. (III.)
Medical Association, and communicated to the Am. Jcurn. Med. Sci. for
publication, in compliance with a vote of the Society?)

I cannot suppose that the brief statistics herewith presented will be con-
sidered of great importance, or novel; but the hope of inducing some mem-
bers of the profession to take sufficient interest to examine and note interesting
points in cases under observation, and thus to add to the reliability of the
statistical tables already furnished, as well as to refute errors and false state-
ments that have been published, prompts me to add my mite, without any
favourite theory or hobby to advocate.

It is too much the habit of many to follow in the wake of those who have
gone before, without taking the trouble to stop and think — receiving their
statements as truth, and yielding a ready assent to the hypotheses advanced,
or the suppositions adduced as facts. The only way that truth can be surely

1857.]

Pierson, Statistics of Obstetrical Cases.

discovered is by patient investigation, by collecting and collating isolated facts,
and instituting full and free inquiry as to the validity of the points in ques-
tion.

I am aware that it may be said of the statistics now presented, that the
number of cases is too limited to have any direct and important bearing to
the points set forth. It is but the multiplication of streamlets that forms the
mass of the "father of waters/' which is able to bear on its current the pro-
duce and population of the most flourishing nation of the universe ; and it is
by the accumulation and combination of single facts, that great truths and
important principles are established.

The abstract of cases from which the following is condensed, I have kept
for some time for my own gratification and reference, not thinking, till re-
cently, of presenting it to the profession ; but it occurred to me that it might
interest some one curious in such matters.

I find by referring to my abstract, that of the cases of obstetrics that have
fallen under my care, I have noted two hundred and seventy-four. I regret
that I have not kept note of a larger number, as well as more full details, and
upon some points not noted. I should perhaps have stated before that I do not
claim originality as to the manner of arrangement; but received the plan from
the paper of Jno. G-eo. Metcalf, M. D., in Am. Journ. of Med. Sci., for Oct.,
1847.

1. The 274 cases of delivery gave birth to 279 children, there being five
cases of twins, being 1 to 54a, 0r nearly two per cent.

2. Of the 274 mothers, 272 were married, two were unmarried, and one
had been but three months — making three illegitimate children at least, or 1 to
91$. The mothers of the illegitimate children were all young ; the oldest 23
years; the others about 16 or 17. One claimed her size to be due to an en-
larged spleen, "ague-cake" of five years' standing, and denied being pregnant
till the last extremity. One being obliged from the constant increasing size
to admit the fact, claimed to be only three months advanced in pregnancy,
unless "she was eighteen months gone;" but was soon delivered of a proper
nine months child. The husband of the married one proved himself innocent
of being father to the child, as he was unacquainted with his wife till a few
weeks before marriage.

3. Of the 274 cases the whole number of times each had been pregnant,
was ascertained in 250, and were as follows: 1st pregnancy, 56; 2d, 48; 3d,
47; 4th, 32; 5th, 19 ; 6th, 14; 7th, 14; 8th, 8; 9th, 4; 10th, 4; 11th, 2;
12th, 1; 15th, 1 ; making a total of 887 pregnancies to the 250 patients, or
an average of a little over 3 J to each mother, which goes far to show that the
majority were young. We frequently find a difficulty in ascertaining with
certainty the number of previous pregnancies, as they are often mute concern-
ing abortions.

4. Duration of Labour. — It is perhaps the most difficult of all to state the
exact duration of labour, from the fact that women themselves date its com-

Pierson, Statistics of Obstetrical Oases.

[July

mencenient from very different times; some from the first uneasy sensation
indicating its approach ; others from the intervention of true expulsive labour
pains. I have endeavoured as far as possible to follow the latter. I have
rarely if ever known the beginning of labour protracted more than 24 hours
after there has been a bloody discharge called the "show," though I have
known one case where there was a rupture of the membranes, and a discharge
of the amniotic fluid eight days before labour, and one fifteen days, another
twenty-nine days, and another forty days previous to confinement j in each
there was a full and free discharge at first, and then a dribbling of water until
labour; but in neither was there any discharge of water during labour, and
all had unusually easy and speedy labours, and the children all did well. Of
the 274 cases I have noted the duration in 228; and of this number I find
221 completed within 12 hours, and only 7 over that period; they were as
follows: 2 in I of an hour, 6 in 1 hour, 1 in 1J hour, 20 in 2 hours, 1 in 2£
hours, 34 in 3 hours, 43 in 4 hours, 17 in 5 hours, 48 in 6 hours, 1 in 6j
hours, 7 in 7 hours, 18 in 8 hours, 5 in 9 hours, 10 in 10 hours, 1 in 11
hours, 9 in 12 hours, 1 in 13 hours, 1 in 15 hours, 1 in 18 hours, 1 in 22 hours,
1 in 23 hours, 1 in 24 hours, 1 in 30 hours, averaging nearly 6 J hours. The
case that was protracted to 30 hours was, as it were, compelled to it as follows.
The patient, a young woman, primipara, close built, and carrying a large
child; a "granny" was called to attend, who at every examination, and that very
frequent for the first stages of labour, thrust her whole hand into the vagina;
following up this procedure at almost every pain, producing of course great
swelling and violent inflammation of the parts; the friends at length became
dissatisfied, and sent for a neighbouring physician, but being unable to
get him, sent for a Thompsonian, he being the nearest help to be obtained,
who only bettered the case by not permitting the midwife to examine the pa-
tient quite so frequently, though she had charge of the case with him. But as
the labour progressed, the head of the child was delayed by the rigidity and
swelling of the soft parts; then, in a quandary, the "steam doctor" and the
"granny" held a consultation, and came to the sage conclusion, that "some-
thing was the matter, and that something must be done," and that they "must
get a new start;" and to that end they decided upon the following plan to
accomplish it: They placed the patient topsy-turvy, standing her upon her head,
spread her limbs apart, and forced the child bach by direct pressure upon the
head. The patient was exhausted by this procedure, and it was some time
before pains returned. They became alarmed, and sent for me in great haste,
"to go and cut the child in pieces, as it could not be born whole." I found
the patient completely prostrated, with but slight pains : there was intense
inflammation and swelling of the vagina and external parts, so much so that
she could scarcely bear the most careful touch; found the child dead; patient
said it had been ever since they forced it back. Administered an. opiate,
and enjoined perfect quiet and rest. When she had obtained a little sleep,

1857.]

Pierson, Statistics of Obstetrical Cases.

she roused up refreshed, pains came oa with force, and was soon delivered of
a fine plump child, entirely by the efforts of nature.

5. Flooding is noted to have occurred between the 6th and 9th month in
6 cases; during labour and before delivery in 12 cases; between the birth of
the child and the expulsion of the placenta in 12 cases. In cases of flooding
before the birth of the child, I found it greatly moderated by the rupture of the
membranes, when between the birth of the child and the delivery of the pla-
centa, by exciting the uterus to action and delivery of the same; if not, by the
use of opium and sugar of lead, or direct cold applications. In only three
cases did it become alarming, and two of those were placental presentations.
In the case that assumed the most alarming symptoms, the patient, a stout
and robust woman, expecting daily to be confined, was suddenly awakened at
night by what she supposed to be the rupture of the membranes and escape of
the liquor amnii. She called her husband to go for me as quick as possible,
but before he could dress she discovered her situation, and he instantly started
for me. I saw her in a few moments, and found her in a pool of blood from
her shoulders to her feet, perfectly prostrated, yet flowing in a rapid stream,
and without the slightest pain. Upon examination found the uterus high up,
and the os uteri but slightly dilated, though not rigid. I was enabled to dis-
cover that it was a placental presentation. During examination slight pains
came on and arrested the hemorrhage for a short time; but the pains re-
laxed and the flooding returned. A similar proceeding produced like results,
but no more permanent effect. I endeavoured to induce pains, but without
avail. Decided to proceed at once to turn to deliver (contrary as it is to all
authority to do it in the absence of pain), but I saw the patient must die if I
waited, and knowing that she could not do worse if I proceeded, thought I
would be found trying for the best. Candidly stating to the patient and her
friends the nature and danger of the case, and telling them that according to
statistics there was only about one chance in ten to save her, they readily
and freely submitted to my judgment, and wished me to proceed as quick as
possible. Found some difficulty in dilating the os uteri so as not to detach
the placenta entirely. The child was high up, and the membranes unbroken ;
ruptured them, and proceeded to turn and deliver as carefully as possible.
During the operation slight pains came on, and the womb contracted slowly;
delivered her of a fine large child, weighing 12 pounds, but dead. Removed
the placenta, and by the most perfect quiet and composure, dangerous hemor-
rhage was averted; but for forty-eight hours the slightest effort, even to raise
a hand, or turn her head, or move a foot, reproduced flowing that could alone
be arrested by the application of cold water to the pubic region, and that had
to be continued for some time before it would succeed, but directed always to
desist when it caused a chill to the patient. She ultimately had a rapid and
favourable recovery.

6. Convulsions occurred four times in the 274 cases, in three before and
in one after delivery. One of each was very slight. In one case the patient

Pierson, Statistics of Obstetrical Cases.

[July

was in most violent convulsions for five hours before I saw her — presumed to
be caused by violence received from a drunken husband — she was in her
eighth month. By copious bleeding and free use of antimony, the convul-
sions were mitigated, but continued slightly till the child was born, after
which she remained in a perfectly comatose state for forty-eight hours, when
she ceased to breathe; she never appeared to be conscious but for a moment
or two at a time (and that but twice) after I first saw her. The others all
recovered.

7. Puerperal Fever, in five cases — about 1 in 55, including puerperal peri-
tonitis and metritis, proving fatal in but one case.

8. Presentation. — Of the 279 children the presentation is noted in 265
cases, as follows: vertex, 232; occiput, 20; face to the pubis, 3; foot, 3;
foot and knee, 1 ; face, 1 ; breech, 1 ; side, 1 ; placental, 2. Two of the
foot-presentations were twins. The above shows a very large per cent, were
vertex, and about five per cent, occipital; the percentage of the other very
small. One case of face to pubis was complicated with funis presentation;
labour tedious, and child still-born.

9. Sex. — Of the 279 children the sex is noted in 270, viz., males, 144;
females, 126, being a majority of 18 males.

10. Weight. — Of the 279 children, the weight was ascertained in 248;
of these, 235 were at full time; the aggregate weight of the 235 was 1923
lbs., being an average of a little over 8 lbs. ; there were 88 that weighed 9
lbs. and over, and 28 that weighed 10 lbs. and over; the heaviest weighed
over 12 lbs.

11. Diseased. — Of the 279 children, 3 are noted as diseased; 2 of which
had hydrocephalus, the other not stated.

12. Deformed. — None, unless we except one born with a prominence on
the left clavicle, which I doubt not was caused by an intra-uterine fracture.,
but had become united. The mother had fallen, some six weeks previous, on
the edge of a board, which hurt her very much at the time.

13. Dead-born. — Of the 279 children 19 were stillborn, being nearly 1
in 14; of these, but 7 were at full time; 2 had been dead for some time, and
were putrid; 1 was killed by an officious granny. Those that were not at
full time were 2 at 2d month, 4 at 3d month, 1 at 6th month, 2 at 7th
month, 1 at 8th month, and 2 at 8 J month.

14. Month of Delivery. — The periods at which the 279 children were deli-
vered are thus noted — Month of Pregnancy: —

No. . . . 11111 1 1 _! 6 _5_ 252 Jl_
Month . . 7 I' 7 5' 6' 6]' 7 TV 8~? 8? IP W
If we call all before six months abortions, and after that and before nine
months miscarriages, we have eight cases of abortion and nineteen miscar-
riages. Though I have not much faith in prolonged gestation, I have one
noted as such — but many have claimed that they have gone over their time —
in this case I thought the patient's reasons were good, if ever they are.

1857.]

Pierson, Statistics of Obstetrical Cases.

It will be seen that the child born at five months is not placed among the
stillborn; I have no reason to think that the mother was further advanced
than that, and she thought not quite that; yet the child lived for half an hour
at least. The child that was born at six and a half months lived some six
hours ; the mother was in the last stages of cancer of the breast, and though
she rallied well after delivery, she lived but about twelve hours.

15. Month of the Year the Children were born, is noted as follows: —
January, 32; February, 21; March, 30; April, 26; May, 17; June, 14;

July, 22; August, 26; September, 27 ; October, 22; November, 15; De-
cember, 27. Which was, during the Spring months, 74; Summer, 62;
Autumn, 64; Winter, 80.

16. Hour of Delivery. — Of the 279 children, 166 were born between
midnight and noon, and 113 between noon and midnight.

17. Twins. — In the 274 cases of delivery there were five in which there
were twins. In three cases both children were females, in the other two both
were males. In one case, there was but twelve minutes between the birth of
the children; in two cases fifteen minutes, each; one case half an hour, and
the other one hour and ten minutes. In two of the cases there were ,two
placentas for each pair, but united together. In two cases but one placenta
for each pair, and in the other case two separate placentas. In three of the
cases both of the children were vertex-presentations; in each of the others
one child presented head and the other foot.

18. Force Deliveries. — In the 274 cases of delivery, force was used in but
three cases; two of those were placental presentations, when version and de-
livery were necessary to save the mothers. In the other, craniotomy was per-
formed on a dead child to save the mother, who was rapidly sinking, but, by
the free use of stimulus after delivery, she had a favourable recovery.

19. Time between Birth of Child and Delivery of Placenta, is noted in 252
cases, and were as follows : four were expelled immediately after or with the
child — 1 in 2 minutes, 2 in 3 minutes, 73 in 5 minutes, 14 in 7 minutes, 5
in 8 minutes, 94 in 10 minutes, 6 in 12 minutes, 29 in 15 minutes, 4 in 20
minutes, 5 in 30 minutes, 2 in 40 minutes, 1 in 45 minutes, 2 in 60 minutes,

1 in 1 hour and 20 minutes, 2 in 1 hour and 30 minutes, 3 in 2 hours, 1 in

2 hours and 30 minutes, 1 in 24 hours.

It may be well to state that so soon as the child is handed to the nurse,
my practice is to place my hand upon the abdomen of the mother, and if the
uterus is contracted upon the placenta, without further delay I take hold of
the cord and tighten it, though not to apply force, and generally pains soon
supervene and discharge the placenta. I have had several cases of hour-glass
contraction of the uterus retaining the placenta in the upper portion, when
it has been necessary to introduce the hand to deliver it. The case that was
delayed twenty-four hours, I was merely called to deliver the placenta; the
physician that attended during labour — which was premature — left without
delivering it, though he told them that he had found no difficulty in the
No. LXVIL— July 1857. 5

Pierson, Statistics of Obstetrical Cases.

[July

case except that it was very frail. There were one or two cases where the
placenta was ossified, or points of ossification through the whole mass, and
would break with decided crepitation.

20. Position of Placenta is noted in 162 cases; in 90 it was attached to
the left side of the uterus, 47 to the right side, 13 to the anterior, 5 to the
posterior, 5 to the fundus, and 2 to the os or cervix uteri.

I have used ergot frequently without harm to mother or child, and some-
times greatly to the relief of a worn-out patience, but never, unless the os
uteri is fully dilated, and there is a cessation of labour-pains.

Ether I have also administered in numerous cases, in all with great relief,
some more than others, and have not known ill effects in any case. I have
not used chloroform.

I have known at least two cases where menstruation has been regular dur-
ing the entire period of pregnancy.

Absence of Lochia. — I have known two cases where the patients did not
lose, one not a drop, and the other not a spoonful of blood during labour or
afterwards, and had no lochial discharge during convalescence, and yet both
had a safe and rapid recovery.

Colourless Lochia. — I have also had several cases come under my observa-
tion, in which the lochial discharge was so devoid of colour as not to stain
the clothes, and yet the patients did well.

We can easily conceive of a case that might require legal investigation,
where there had been uninterrupted menstruation during pregnancy, followed
by an absence of lochia or a colourless discharge — which might lead to some
difficulty in coming to a just decision.

Unbroken Hymen. — I was called to attend upon a lady in labour, who had
been married about a year, and upon making an examination to discover the
progress of the labour, found that the hymen was unbroken, the orifice not
being large enough to admit the tip of my finger. It was ruptured without
difficulty, and the case had a happy issue.

Occlusion of the Vagina. — A case of almost complete occlusion of the vagina,
caused by officious handling and unwarrantable abuse during a previous labour,
producing violent inflammation and adhesion of the wall of the vagina to such
an extent that the patient and her husband thought it impossible for her to
become pregnant, and would not believe that she was so, till forced by attending
circumstances to admit the fact. When labour supervened, I was sent for —
about thirteen miles; — when I arrived, found her under the most violent
expulsive pains, and the only orifice thus fully dilated would not more than
admit a goose-quill. I explained the nature of the case, and the danger of
an operation under such circumstances, viz., of vesico- vaginal and recto-vaginal
fistulae — from the ease with which the divided parts would tear, and thus
extend to the rectum and bladder. But being urged to prompt action by the
patient and her friends, and knowing that the only recourse was to operate

1857.]

Pierson, Statistics of Obstetrical Cases.

with care, and endeavour to support the parts during the progress of labour,
I proceeded with a probe-pointed bistoury to enlarge the opening, and so soon
as possible to explore with my left index finger as I advanced. The complete
and firm adhesion was from one half inch at the anterior, to one and one-half
inches at the posterior part of the vagina, the whole distance cutting through
solid flesh or cicatrix. The adhesion was from the internal labia inward.
There were also several large and rigid cicatrices still farther inward, that I
was obliged to divide before the head of the child could pass — as they were
hard and unyielding bands that would not admit of distension more than a
whip-cord.

As I feared, and stated to the patient, the cut surface lacerated posteri-
orly to the rectum, producing a very small recto-vaginal fistula, though so
small as never to trouble her; it also tore anteriorly to the neck of the
bladder, producing a vesico-vaginal fistula — for which I have operated, and
she has since been entirely relieved from all trouble on that account. I have
since attended her during labour, and she had in every respect a favourable
labour and convalescence. In a medico-legal point of view, the two preceding
cases go to show that pregnancy may take place without the introduction
of the penis.

I have one patient in whom the secretion of milk took place at four and a
half months of pregnancy — she went her full time, and " never had a dry
bosom for an hour at a time, for four and a half months before delivery."
The secretion was very copious.

One child numbered in the foregoing abstract was born with the membranes
entire — it was the last of a pair of twins at eight and a half months.

One child was born with leucorrhcea, which lasted two days, when occurred
a regular appearing menstrual discharge, which continued four days.

Pregnancy without sexual pleasure. — A very intelligent lady, who has been
married for some time, had the usual symptoms of pregnancy, and the object
of her inquiry was, whether such could be the case, whereas she had never
enjoyed the least pleasure during copulation, but it was to her a matter of in-
difference, so far as desires were concerned; yet the result proved that she
was then some three or four months advanced in pregnancy. She is a lady
whose word is above suspicion, and her very manner of inquiry would forbid
the thought of it, and she was desirous to know wherefore these symptoms,
when she thought pregnancy out of the question under the circumstances.

I have known also two other very similar cases, in which there was no
pleasure arising from coition, and in one it was always a matter of repug-
nance, and still pregnancy took place. One patient that had been pregnant
six or eight times, has always become so whilst in the act of menstruating,
and she believes that in her case it would be impossible to become so at any
other time.

As already said, I am aware there is little or nothing, in this paper to ex-

64 Gallaher, Potash in Mercurial Stomatitis. [July

cite wonder, and some of the latter statements may not be considered in place
in connection with the abstract; but I report them as growing out of the same
cases, and on account of their rarity.
Augusta, III., April, 1857.

Art. VI. — Chlorate of Potash in Mercurial Stomatitis. By Thomas J.
Gallaher, M. D., one of the Physicians to the Western Pennsylvania
Hospital, Pittsburg.

Mercurial stomatitis is a most loathsome and obstinate complaint. Slight
attacks of this affection are comparatively of but little consequence, for, with
proper precautions as to exposure, they will mostly disappear in a short time
without remedial measures being resorted to. More grave forms, how-
ever, in which the gums become very sore, the tongue swollen, the mucous
membrane of the mouth ulcerated, the salivary and other glands in the
vicinity of the neck enlarged and tender, the breath fetid, the jaws stiffened,
deglutition difficult, salivary secretion increased, &c, are of more serious im-
port, and demand the attention of the physician. If a case of this kind be
left to itself, or if merely palliatives be employed, it will generally last some
weeks, and it may be months before its complete removal by nature is effected.

Many remedies have been suggested and various plans of treatment tried for
the removal of this artificial malady; but none, until the chlorate of potash
was proposed, met the wants of the profession, and none gave general satisfac-
tion. Hecent authors have generally contented themselves with recommend-
ing exposure to a warm dry air, cathartic medicines, topical depletion, and
the local application of numerous washes — demulcent, astringent, and stimu-
lating— to the inflamed parts. How uncertain and unsatisfactory these means
have been, the profession everywhere can answer. For my part, I may say
that I have often been so dissatisfied with the slowness with which mercurial
sore throat disappeared under this treatment, that I thought no good was
derived from it further than temporary amelioration of disagreeable symptoms
and preservation from external injurious influences. This treatment is emi-
nently palliative — not specific. Present relief is afforded — while the affection
is allowed, in a great measure, to run its own course.

Recently, a new remedy has been proposed which, from a pretty extensive
employment of it, I now regard as much a specific for mercurial stomatitis
as quinia is for intermittent fever.

Ihr was the first to recommend the use of the chlorate of potash in ulcera-
tion of the mouth following salivation, but to Messrs. Herpin and Blache, of
Geneva, are we indebted for a more full and satisfactory account of the

1857.]

G-allaher, Potash in Mercurial Stomatitis.

beneficial effects of this salt in mercurial stomatitis in all its forms and stages.
The first account of the discovery of these eminent physicians which appeared
in this country, was published, I believe, in the April No. of the American
Journal for 1855. Since that time I have had frequent opportunities for
employing it, and uniformly with success. I have seen ordinary mercurial
stomatitis disappear under its use in a few days, while the most loathsome
forms have been observed to yield in ten. Judging from past experience,
I now, with the use of this salt, can remove a mercurial disease of the
mouth in from six to ten days, which, under any other proposed plan of
treatment, would last from four to six weeks. I may say that I have found
it equally beneficial in all stages and degrees of salivation, as well as in
ulceration of the mucous membrane of the mouth, which sometimes remains
after the other symptoms have disappeared.

My method of treating a patient affected with this disease is as follows :
He is placed in a warm and comfortable apartment, and made to live on gruel.
I then order him" ten grains of the chlorate of potash, dissolved in a table-
spoonful of cold water, three or four times a day, according to the severity of
the affection. Should there be ulceration of any portion of the mucous
membrane of the mouth, I direct a weak solution of the salt to be applied to
the denuded part several times a day. Generally, nothing else is required —
the cure being accomplished in a few days. To illustrate more fully the effect
of this remedy, I have appended a few cases, which have been selected from
quite a number that have fallen under my notice.

Case I. The first case in which I had an opportunity of employing this
remedy, was in May, 1855, on the person of a young lady, aged 26 years.
Blue mass pills had been given her pretty liberally, by the family, for some
imagined illness, until her gums and mouth became so sore that it was with
difficulty she could swallow food. After suffering some days under these
symptoms, I was called to visit her. I found her breath fetid, gums sore,
mucous membrane of the mouth partially ulcerated, and other unmistakable
evidences of confirmed salivation. For a few days I gave the usual mouth
washes, a gentle cathartic, and required her to remain confined to her room.
For about one week she used the means I suggested, with but little advantage.
At this time I was made acquainted with the good effects of chlorate of potash
in mercurial stomatitis, and at once determined to put it to the test. I accord-
ingly prescribed it as follows : R. — Potass, chlorat. 3ij ; aquas ^vj. — M. One
tablespoon ful of this solution to be taken three times a day. I saw the
patient two days afterwards, and found her much better. Her mouth had
commenced to heal, the mercurial fetor of the breath had diminished, and she
felt able to swallow food. In a week from this time the disease was entirely
removed.

The speedy relief obtained in this case gave me some confidence in the new
remedy, and satisfied me that it was worthy of further trial. An opportunity
soon occurred.

Case II. Miss C , aged 23 years, while employed in the capacity of a

dry nurse, was attacked in the spring of 1856, with severe neuralgia of the

Brown; Potash Injections in Lencorrhoea.

[July

right side of the head and upper part of the face. The physician to the family
in which she for the present resided was called to see her, who pronounced it
disease of the brain. Powders containing calomel were ordered. She took
the medicine a few days, but her mouth becoming very sore, and her sufferings
not being alleviated but rather increased, her friends determined to take her
home and send for their family physician. I found the patient labouring
under remitting hemicrania of most excruciating severity, accompanied with
mercurial salivation. The severity of the symptoms requiring active medica-
tion, I ordered at once remedies both for the neuralgia and sore mouth. A
liniment, composed of chloroform and olive oil, was ordered to be applied to
the head and temples, and ten grains of the sulph. of quinia to be given night
and morning, for the former, while ten grains of the chlorate of potash, three
times a day, was prescribed for the latter affection. In three days the hemi-
eranial pain had subsided, when the quinia was suspended. The sore mouth
had, in the mean time, improved. Four days' more employment of the
chlorate stopped the salivary discharge, and healed up the mouth. The cure
was prompt and decisive.

Case III. In January, 1857, 1 was called to visit a Mrs. M , who com-
plained of a bad breath, sore mouth, loss of appetite, &c. I learned that,
about one week previous to my visit, she had taken some anti-bilious pills,
which were supposed to contain mercury. An examination of the mouth told
at once the cause of her sufferings. She was severely salivated. Nothing had
been done, further than a Dover's powder had been taken at bedtime, to work
the cold off, as she expressed it, and an alum wash for the mouth had been
used freely. It may not be improper to state that no advantage was derived
from these. The patient was directed to remain in her room, live on spoon
diet, and take the chlorate in ten grain doses, three times a day. On my
visit the following day, she was much better, and declared the first dose helped
her. A continuance in the remedy effected a perfect cure in a few days.

Case IY. This was a case of ulceration of the mouth following salivation.
It was of nearly three weeks' continuance, and many local applications, in-
cluding nitrate of silver, had been ineffectually made to it. I gave the chlorate
in the usual form and frequency, and ordered the ulcer — which was situated
beneath the tongue, of large size and very painful — to be washed several times
a day with a weak solution of the game, and had the satisfaction of seeing it
heal up in five days.

ART. VII.-— Chlorate of Potash Injections in Leucorrhoza and Ulceration of
the Os Uteri. By Bedford Brown, M. D., Caswell County, N. C.

Knowing the peculiar and happy curative influence exerted by chlorate
of potash in external ulcerations attended with vitiated discharges, and having
been so often disappointed by the usual modes of treating such cases, the great
difficulty of which all medical men acknowledge, I determined to experiment
with injections of a solution of that salt in ulceration of the os uteri and cer-
vical canal attended with leucorrhoea.

1857.]

Brown, Potash Injections in Leucorrhoea.

The discovery of some simple and efficient means as a substitute for the
uncertain astringent injections in common use, and the tedious and often
unsuccessful caustic and speculum, would relieve the physician of an extremely
disagreeable duty, and the patient of an almost intolerable necessity.

In those cases of leucorrhoea attended with ulceration of the os uteri or
cervical canal, and enlargement of the muciparous glands of the vagina, or
simple ulceration without leucorrhoea, I believe the injections of the chlorate
far more certain and efficient than the ordinary astringent injections, or the
local application of caustic. In these cases I have not thought proper to give
detailed reports of their symptoms and progress.

Case I. A coloured woman, aged 30, who had never borne children, and
had, from early life, complained of symptoms of uterine disease. At the
time she came under my charge, she had profuse leucorrhoea. On examination
with the speculum, the entire vaginal canal was seen highly inflamed — the os
uteri very tumid, with numerous large ulcers. This woman used, by injection,
a solution of the chlorate, in the proportion of 3j of the salt, dissolved in
^viij of rain water. As much of this as an ordinary female syringe contains
was used twice daily. Under its influence the ulceration and inflammation,
with the attendant leucorrhoea, diminished rapidly, and in two weeks all indi-
cations of disease had disappeared. In this case, the locality of the disease
was confined to the vagina and the os uteri.

Case II. To digress from the subject, I would report the present case as
illustrating the equal powers of the chlorate of potash in gonorrhoea of the
female. This patient, an unmarried female had suffered from gouorrhoeal
disease, until the vaginal inflammation had become excessive with very copious,
purulent, and exhausting discharges, accompanied by so much tenderness and
pain as entirely to preclude the use of the speculum. The difficulty and pain
of urination were such as to compel me to use the catheter frequently. The
same treatment as in the previous case was adopted, and with equal success.
In fact, this patient (servant) who had been perfectly disabled, in ten days
after using the chlorate injections, was attending to her ordinary duties.

I strongly conjecture that gonorrhoea of the male would be equally amenable
to the same treatment; and, as soon as the first opportunity presents, I design
testing it. If so, a new era will be introduced in the management of that
intractable disease.

Case III. This was an example of leucorrhoea originating from ulceration
of the os uteri and inflammation of the cervical canal. The woman was
married, and had been confined prematurely three months previous. She used
the chlorate of potash injections, and remained in the recumbent position for
some hours after each injection. She found equal benefit from the remedy,
and is now attending to her customary duties, without any of her former
symptoms.

Cases IV. and V. In these cases there was ulceration of the os uteri and
cervix, with very slight leucorrhoea, though suffering from the ordinary annoy-
ing symptoms of uterine affection. I both cases, the chlorate in solution
healed the ulcerations in between two and three weeks, with signal relief to
the patient.

68 Casselberry, Wafer in Treatment of Fever. [July

To sum up briefly, those conditions to which the chlorate of potash injec-
tions are applicable, I would say those cases are appropriate, wherein ulceration
and inflammation are confined to the os uteri and cervical canal and vagina,
either with or without leucorrhoea.

Art. VIII. — The Use of Water in the Treatment of Fever. By Isaac
Casselberry, M. D., Evansville, Ind.

Anatomy. — The skin has, in man, a superficies of about fifteen square feet.
It is composed of three coats : an outer, called the cuticle, or epidermis, of a
horny nature; a middle, of a soft pulpy consistence called rete mucosum, or
mucous body; and an inner, of a dense resisting character called the true skin
or chorion.

On the upper surface of the true skin are distributed, in great profusion,
nerves and small vessels; some of these vessels convey blood; others, lymph;
surrounding and penetrating the coats of these vessels to their most minute
distribution are the automatic nervous branches. This is the nerve of the
blood, absorbent, and secretory vessels ; and wherever they ramify they carry
along with them minute branches of this nervous system. It creates, main-
tains, and governs the functions of these vessels.

The cuticle has no sensibility, and is, therefore, wonderfully adapted to the
protection of the nerves, glands, and vessels of the other coats. It has open-
ings, or pores, which admit the escape of perspirable matter and certain gases
secreted by the glands under the mucus coat and upon the true skin. These
openings are not direct communications; they go some way obliquely under
the cuticle before they open externally. On the upper surface of the true
skin and immediately under the mucous coat are a countless number of glands
of secretion and of absorption. Some of these glands display functions nearly
identical with those of the lungs in respiration. They secrete the same gases
and absorb the same gas as the lungs.

The community of function between some of the glands of the skin and
those of the lungs is so nearly identical, that, in some animals, as the common
leech, both are performed by the skin; and in others, as the frog, which will
survive longer the excision of the lungs than the loss of the skin.

The skin has a continuity of structure with the lining membrane of the
respiratory, the digestive, the urinary, and the uterine passages. This is the
physiological reason why the states of the skin both modify and are modified
by the functions of respiration, digestion, and urination. The mucous coat of
the skin, in some degree, protects the vessels, nerves, and glands from com-
pression and contusion. While the cuticle is hard and the true skin firm, this
is soft and yielding. The cutaneous glands have a perfect glandular organ-

1857.]

Casselberry, Water in Treatment of Fever.

ization. The arterial, venous, lymphatic, and capillary vessels, and the auto-
matic nervous branches, minutely ramify through its structure.

Physiology. — Blood, rich in nutritive and effete elements, is conveyed along
the arteries to the capillaries in which it undergoes a series of cellular changes,
by which the nutritive are separated from the effete. Each class of these
elements undergoes further molecular changes by which the former is prepared
and appropriated to the nutrition of the different external tissues ; while the
latter is elaborated and coalesced into various secretory elements, and removed
from the cutaneous tissues in the form of compounds, as sweat, carbonic acid
gas, &c. These molecular mutations are accelerated by the absorption of oxygen
from the atmosphere by certain cutaneous glands in a mode nearly identical
with that in which the lungs absorb atmospheric oxygen ; and oxygen in the
external capillaries combines with the carbon of the food, evolves heat, and is
removed by secretory action in the form of carbonic gas. When these ele-
ments are combined in the lungs heat is evolved, and carbonic gas formed
and secreted.

Are not the functions of the lungs and those of the skin, in this particular,
identical ? They certainly produce the same results.

When the blood arrives in the external capillaries its elementary composi-
tion is not the same as when it was returned from the luogs into the left side
of the heart, because it is a living and growing fluid. From the time the
organizing force of the automatic nervous branches at the mouths of the
absorbent vessels begins to act on the organizable elements of the food and
drink until the blood is conveyed to the tissues it is designed to nourish, it is
in a state of constant growth, when it attains maturity and is appropriated.
Every tissue of the organism is nourished by its own capillary vessels designed
for that particular purpose. The living circulating mass supplies the material
out of which the automatic nervous force of these vessels elaborates and appro-
priates the nourishment of the tissues. When the blood is normal the dif-
ferent forms of the automatic nervous force readily obtain a supply of nutrient
material ; and all the functions of the organism are performed with comfort
and regularity.

Not only the blood has a period of incipiency, growth, and maturity, but
so, also, has each cell of which it is composed. For practical purposes, the
cells of the blood may be arranged into two classes : one, to nourish and build
up; the other, to tear down and remove. When the human organism arrives
at maturity they should be exactly equal to each other. From this physiolo-
gical fact it is evident that a normal quantity of blood must be conveyed into
the external capillaries, in which it must undergo normal molecular changes
in order to maintain the external tissues in a healthy condition.

Pathology. — If, from any cause, the blood is not conveyed to these vessels
in normal quantity and quality, the temperature of the skin will be abnormal.
This is fully evinced in every state of fever, from its incipiency to its termina-
tion. I have endeavored to show that the automatic nervous system creates,

Casselberry, Water in Treatment of Fever.

[July

maintains, and governs the circulation of the blood, and produces all the
molecular changes which occur in the capillaries (Amer. Med. Journ., July,
1855); and that, therefore, the primary link in the series of functional lesions
which produce fever must be a lesion of this force in these vessels ( Amer. Med.
Journ.j April, 1856).

From the physical position and anatomical structure of the arterial, capil-
lary, and venous systems of the skin, and from their physiological relation of
function to that of these systems in the other great depuratory glands, the
liver, the kidneys, and the lungs, it is evident that the primary impression of
the electrical disturbance in the atmosphere, the disturbing force of which
produces a lesion of the automatic nervous force, must first take place in these
vessels.

The degree of lesion between the elements of the blood in the external
capillaries depends on that of the electrical disturbance, and that of the resist-
ance to the force of this disturbing cause offered by the organism. It may
be slight, when it will soon be removed by the superior force of the different
forms of the normal automatic nervous force in these vessels. But each time
this lesion is produced by an electrical disturbance in the atmosphere, the less
the degree of resistance offered by the organism; so that by the frequent
repetition of the electrical disturbance, although it may not be, at any time,
increased in intensity, a diseased state of all the elements of the blood will be
gradually produced. This is fully evinced by the ordinary symptoms of fever.

The disturbing force of electricity may be of sufficient intensity and dura-
tion to produce a diseased transformation of all the tissues in a few hours.
Then the most malignant symptoms of fever are manifested. When fever is
produced in the former mode, by the gradual disturbance of the normal rela-
tion between the elements of the blood, the skin is either hot and dry, or cool
and bathed in perspiration.

During the progress of fever the skin often communicates the sensation of
increased heat, when its temperature, as indicated by the thermometer, is not
augmented, because the skin, when dry, is a better conductor than when moist,
and because no increments of heat are lost by transmutation into mechanical
force by which sweat is driven from the surface. The sufferer often imagines
he is almost burning up, when the temperature of the skin evinces no increase
of heat. Why is this ?

The pathology of the blood reveals the answer. All of its elements are in
a state of diseased transformation. The different forms of the automatic nerv-
ous force normally manifested as nutritive attraction by which the tissues are
nourished, and effete repulsion, by which they are freed of effete elements,
are, in some degree, changed into abnormal or chemical force. Hence the
elements of the blood are abnormally transformed; they do not nourish the
tissues, but they are the agents used by the chemical force to facilitate the
molecular decomposition of the solid tissues. The organizing force of the
digestive organs no longer attracts the organizable elements of the food. New

1857.]

Casselberry, Water in Treatment of Fever.

material for normal blood is not absorbed and elaborated. The growth of the
blood is soon arrested when the superior quantity of the augmented chemical
force transmutes its elements abnormally and produces their re-arrangement
in accordance with chemical laws.

When the elements of the blood are abnormally transformed, the albumi-
nous undergo imperfect molecular development. The organizing force of
these elements attracts the oxygen of the atmosphere imperfectly, because of
their deficient molecular arrangement in the pulmonic and cutaneous capilla-
ries. A limited quantity only is absorbed. This oxygen is an important
nutritive constituent of the albuminous compounds. They cannot attain per-
fect molecular growth without its elementary combination with the other ele-
ments of the protein compounds. When, from any cause, this combination is
imperfect, the molecular development of the protein compounds must there-
fore partake of this imperfection. The automatic nervous force, which is
manifested between the elements of these compounds in the form of nutritive
attraction, is increased in some capillaries, decreased in others, and perverted
in all.

When the organizing force of the protein elements is in this manner dis-
turbed, they may attract the oxygen of the atmosphere, and cause its absorp-
tion, either by the pulmonic or cutaneous capillaries but, when absorbed, it
cannot undergo normal cellular development and combination with the other
elements of the protein compounds, because of the lesion of the organizing or
nutritive force. Its presence sometimes gives perverted motion, but always
diminished power, to the organizing force. Hence the manifestations of this
force is then irregular and imperfect. Neither the nutritive nor the effete
elements undergo normal mutations. Secretion is increased in the capillaries
of some of the glands, decreased in those of others, and perverted in all.

Animal heat is produced by the normal molecular changes the elements of
the blood undergo in the capillaries of the organism. It is generated as much
by the food we eat and the fluids we drink, as by the oxygen we inspire. It
is not developed by a simple chemical combination of the carbon of the food
and of the oxygen of the atmosphere. To generate and develop animal heat
is one of the series of the processes of nutrition ; unless all these processes
are normal, the quantity of heat cannot therefore be normal.

When lesion of nutrition and secretion exists in all the tissues, the cellular
changes of the nutritive and effete elements are not performed with normal
regularity and in normal quantity; because the oxygen of the atmosphere,
absorbed by the glands in the pulmonic and cutaneous capillaries, is acted
upon by the organizing force in some of the capillaries only; while, in others,
it is not consumed by molecular combination, but remains, in a great degree,
free to combine, not only with the abnormal elements of the blood, but also
with the protein elements of the solid tissues. The consuming force of the
free oxygen, acting upon the organizing force of the solid tissues, produces in
those tissues, to which branches of the sensitive nervous system are distri-

Casselberry, Water in Treatment of Fever.

[July

buted, the sensation of heat, or burning and pain ; in those to which excito-
motory branches are distributed it causes irregular and involuntary muscular
action ; and in the blood, which has no other nervous endowment except that
of the automatic, it augments the lesion between the elements of the blood,
produces the sensation of thirst, facilitates the formation of congestion and
inflammation, and accelerates the molecular changes of the different forms of
the automatic nervous force into that of the chemical.

When the different forms of the chemical force, which is an abnormal mani-
festation of the automatic, are extended to the sensitive and excito-motory tis-
sues, a shivering or chill is developed ; manifestations of augmented and per-
verted sensation and irregular and involuntary muscular motions transpire ;
a lesion of circulation in the external capillaries exists; the blood is neither
normally attracted nor normally received in these vessels; the muscular action
of the heart and arteries becomes tumultuous ; an abnormal quantity of blood
accumulates in the thoracic and abdominal venous systems.

The molecular changes of the normal automatic nervous force of the ex-
ternal capillaries consumes by cellular combination the excess of the chemical
force between the elements of the diminished quantity of blood remaining in
these vessels ; the sensation of warmth is restored ; muscular action is tran-
quillized ; the blood, greatly contaminated by the retained effete elements of
the food and of the transformed tissues, begins to return in increased quantity
to the external capillaries, whose normal organizing force consumes, in some
degree, the different forms of the chemical force between the elementary con-
stituents of the blood • removes a quantity of the effete elements by secretion,
and conveys the blood, thus partially depurated, into the venous branches, by
which it is returned to the heart. The mechanical force of the muscular
action of the heart propels the blood into the arteries, in which it undergoes
a continued series of molecular changes till it is conveyed into the capillaries,
in which a different and an augmented cellular mutation transpires, a quan-
tity of effete elements are removed by secretion, and the blood again conducted
into the venous branches.

When the organizing force of the automatic nervous system is superior in
intensity to that of the different forms of the chemical, each time the blood is
conveyed through any of the great depurating glandular systems a quantity of
its effete elements are removed by secretion; but when the organizing force is
inferior in intensity to that of the chemical, the blood becomes more and more
contaminated by the effete elements of the transformed tissues of the organism,
until the organizing force is consumed by the molecular changes of the mul-
tiplied forms of the chemical, and life is extinguished.

The depuratory glands maintain a complementary relation of function with
each other ; and it seldom occurs that the functions of all are alike diseased.
When the lungs, the liver, or the kidneys are congested, the skin is always
anaemic; when inflammation, which is excessive and perverted nutrition,
exists in any of these glands, the external tissues are always more or less

1857.]

Casselberry, Water in Treatment of Fever.

bloodless, according to the duration and degree of that diseased condition and
the causes by which it is produced j and when the external capillaries are
congested, or when they are the seat of excessive and perverted nutrition, the
circulation in the other depuratory glands, especially the liver and the kidneys,
are proportionally disturbed. From the anatomical structure of the portal venous
system, the capillaries of the liver and the kidneys are more liable to con-
gestion than those of the lungs, when a recession of blood takes place from
the external capillaries; because the veins in this system, like those in the
lungs, are without valves, but of larger size, and in a position more favourable
for the reception and lodgement of blood by its retrograde movement from the
right side of the heart. When lesion of circulation exists in the external
capillaries, a reflux of blood into the portal system always occurs in a propor-
tion of direct equivalence to the degree of this lesion.

Either a determination of blood or a congestion in the hepatic, the renal,
or the intestinal capillaries, may be produced according to the duration, re-
petition and intensity of the disturbing cause and the degree of resistance
offered by the organism.

When the blood is determined to the liver by recession from the external
capillaries, retaining effete elements which should have been removed by the
depuratory glands of the skin, the presence of an increased quantity of abnor-
mal blood in the hepatic capillaries is always evinced by the secretion of an
augmented quantity of bile, which is often perverted in quality.

Congestion of the liver exists, when the molecular changes of the blood iu
the hepatic capillaries is, in a great degree, controlled by the superior inten-
sity of the chemical force. The secretion of bile is then always greatly de-
creased, until the automatic nervous force of the capillaries is almost wholly
transmuted into chemical, when the biliary secretion is largely augmented in
quantity, but altered and perverted in quality. These conditions of the biliary
secretion have often been observed in this climate, when the days aie hot and
the nights cool, in alluvion districts abounding in stagnant water ; and in a
more southern climate, when the dew-point is high, a perverted state of the
biliary compound is always present during fever.

Lesion of the external capillary circulation must always take place before a
determination of blood to the liver and kidneys, or a congestion in these
glands, can occur. The blood must recede from the external capillaries' into
the portal system, and its retention there must be favoured by the imperfect
introduction of the blood from the arterial branches into these vessels; because,
when the blood is normally admitted into them, the equilibrium of the circu-
lation is soon restored, and the abnormal accumulation of the blood in the
portal system ceases to exist.

A bilious derangement cannot, therefore, be produced without a previous
lesion of the circulation in the external capillaries. All the tissues are formed
by the organizing force of the automatic nervous system out of the organizable
material of the maternal blood during embryotic life; and, after birth, they

74 Casselberry, Water in Treatment of Fever. [July

are nourished and sustained, decomposed and removed by the varied and dif-
ferent forms of this force. Cells are the agents which it employs to perform
all its functions in the organism. Throughout every tissue they obey the
mandates of this force. Hence what they do, whether normal or abnormal,
indicates the state of this force in its multiplied forms. Their physiological
productions and pathological manifestations should, therefore, be attentively
observed and assiduously studied.

When the organizing force is diminished in quantity and weakened in
intensity in the external capillaries by a recession of blood from these vessels
to the venous system of the thorax and abdomen, caused by electrical dis-
turbance in the atmosphere, and by the retention of the effete elements of the
food and of the transformed tissues, it is of the first importance to determine,
with some degree of confidence and certainty, the compensatory assistance
which its vast multiplicity of forms in other tissues will lend to restore it to
a normal condition in these vessels. They are all endowments of the organ-
ism ; all they do is for its conservation ; but what can they do now ?

The blood is diseased by a lesion of the organizing force between its ele-
ments ; many of its cells neither grow nor mature ; they contain organizable
constituents ; these are not organized normally by normal forms of the or-
ganizing force ; but abnormally, by perverted forms of this force ; they aggre-
gate and constitute either congestion or inflammation, or both, in the great
depuratory glands. There is a lesion of nutrition; the supply of nutritive
material is proportionally diminished; only a small number of new recruits
are mustered into the service of the organism ; these have not been trained
to obey the commands of the organizing force ; they too often desert and seek
association among the tumultuous host governed by chemical force. There is
not a sufficient quantity of normal cells which undergo normal molecular
changes to maintain a perfect equilibrium between the processes of waste and
repair. Their quantity must be increased. How can this be done ? Not by
the introduction of nutritive elements ; but by the depuration of those which
already exist among the other elements of the blood. This can only be ac-
complished by molecular changes of these elements, by which the effete are
elaborated and separated from the nutritive.

The diminished quantity of the organizing force in the external capillaries,
caused by recession of blood from these vessels into the portal venous system
chiefly, the superior intensity of the chemical force in the blood, thus accu-
mulated in this system in augmented quantity but perverted quality, and the
consuming force of the imperfectly combined oxygen of the atmosphere, in-
troduced into the blood at each inspiration, resist the fulfilment of this restora-
tive indication. The imperfectly combined oxygen is not only consuming, by
molecular combination, the nutritive elements of the blood, but also the solid
tissues.

A complete lesion of nutrition is soon produced; the chemical force, in its
multiplied forms, rapidly augments in intensity by superior quantity ; the

1857.]

Casselberry, Water in Treatment of Fever.

sensations of thirst and of increased heat are urgent and agonizing ; pain is felt ;
oxygen is consuming the sensitive nervous branches.

The first indication to be fulfilled is the removal of this oxygen. This must
be done by molecular combination.

As vacuity always favours absorption and repletion retards it ; and as the ex-
ternal capillaries are comparatively in the former condition, while the hepatic
and renal capillaries are strictly in the latter, it follows that absorption would
take place with much more celerity in the former. When this abnormal state
of the circulation is associated with the physiological fact, that the different
forms of the automatic nervous force maintain and control the elements of the
blood in the external capillaries, while pathology as plainly indicates that
those of the chemical predominate more or less over these elements in the vis-
ceral capillaries, a comprehensive appreciation of the varied functions of the
organism and of the compensatory assistance they afford each other, most con-
clusively show, that curative means should be addressed to the external capil-
laries commensurate with their depurative and compensatory functions.

This proposition is supported by the anatomy and physiology of the cuta-
neous tissues as well as their physiological relation of function and pathological
compensatory assistance. We have abundant evidence that the sensitive and
excito-motory nervous branches are largely distributed to the tissues, through
which the external capillaries are ramified, by which these nervous branches
are supplied with nourishment, and receive the disturbing impression of the
chemical force ; that the tissues to which the visceral capillaries are distributed
have no sensitive and excito-motory endowments ; that the sensitive nervous
system is the agent the automatic employs to bring the organism into relation
with the external world ; that the excito-motory is the agent it uses to protect
the organism from external objects; and that these two nervous systems often
lend a compensatory aid to the automatic. Their restoration and conservation
should, therefore, always be a primary object.

The existence of imperfectly combined oxygen in the external capillaries
will, for this physiological reason, be instantly evinced by the sensation of
pain and increased heat of the skin and the manifestation of involuntary mus-
cular motions, while a proportionate quantity of uncombined oxygen in the
visceral capillaries, which have not these nervous endowments, would only
excite the sensation of thirst and oppression. The imperfectly combined oxy-
gen should, therefore, be consumed by molecular combination in the external
capillaries and be removed by secretion, so that the sensitive and excito-mo-
tory systems would be in a condition to lend compensatory assistance to the
automatic in the depuration of the blood in the other depuratory glands. How
can the removal of the imperfectly combined oxygen of the atmosphere in the
external capillaries be accomplished ? By the use of water. Its temperature
and its mode of application must be governed by the state of the different
forms of the automatic nervous force. This is indicated by the augmented
or diminished quantity of blood in the external capillaries; by the tempera-

Casselberry, Water in Treatment of Fever.

[July

ture of the skin; by the mechanical force of the muscular action of the heart
and arteries j by the state of the venous system, whether congestion exists in
any of the great depuratory glands or not; by the decreased and perverted, or
the increased and perverted, sensibility of the sensitive nervous system ; by
the irregular and involuntary muscular motions of the excito-motory system;
by the lesion of the nutritive process ; and by that of those of secretion.

When warm water is properly applied to the cool skin, a certain quantity
of its heat is instantly transmuted into animal electricity. This gives in-
creased intensity to all the forms of the automatic nervous force; the molecu-
lar changes of the blood are augmented and accelerated ; water is absorbed ;
the imperfectly combined oxygen in the blood attracts the hydrogen of the
water, combines with it, and is secreted in the form of sweat; the oxygen of
the water combines with the carbon of the blood, evolves heat, and is secreted
in the form of carbonic acid gas. A comfortably soothing sensation reigns
supremely through the tissues endowed with sensitive nervous branches. The
external capillary circulation is greatly augmented and accelerated ; an in-
creased quantity of arterial blood is attracted and introduced into these vessels
by the superior intensity of the molecular changes of its elements; the me-
chanical force of the muscular action of the heart and arteries is stronger and
more tranquil; respiration is freer and less hurried; copious sweating ensues;
and a large quantity of effete elements are depurated from the blood.

When the skin is hot and dry the water used should be cool. Why? Be-
cause there is an abnormal quantity of animal heat and electricity retained in
the external capillaries by deficient secretion.

The low temperature of the water increases its capacity for animal heat and
electricity, and promotes the affinity of its elements for each other. When it
is applied and retained upon the skin, it attracts animal heat and electricity,
and causes the secretion of an increased quantity by the cutaneous glands.
When the aggregated heat and electricity are thus removed, the different
forms of the organizing force assume increased activity ; water is absorbed and
decomposed; the molecular changes, which then ensue, are the same as those
that transpire when warm water is employed.

Sweating may and often does transpire freely without any considerable
diminution of the temperature of the skin ; because it is only one of the pro-
cesses of the secretion which takes place in the cutaneous glands. In this
state of the skin, the indications for the employment of cool water are nearly
the same as when it is hot and dry.

While portal congestion exists, neither the external nor the internal use of
water is adequate to the restoration of the functions of the glands, to which
this venous system is tributary; because the hepatic, renal, and intestinal
capillaries are replete to distension ; and only a small portion of this blood
passes into the pulmonary circulation in consequence of its retrograde motion
from the right side of the heart, or of the enfeebled mechanical force of the
muscular action of this organ. The almost complete transmutation of the dif-

1857.] Casselberry, Water in Treatment of Fever. 77

ferent forms of the automatic nervous force into those of chemical, by the su-
perior intensity of the augmented quantity of which the molecular changes of
the blood in these vessels are governed, causes the absorption and secretion of
the hepatic, renal, and intestinal glands to be either greatly decreased in
quantity and vastly altered in quality, or largely augmented in amount and
wonderfully perverted in elementary arrangement and chemical composition.
If, therefore, water be introduced, either by drinking or by injection, into the
alimentary canal, it cannot be normally absorbed, nor can it undergo normal
molecular changes, because chemical force prevails over the cellular changes
which transpire between the elements of the blood and the solid tissues.
Water cannot then be normally absorbed, and, if it be abnormally taken into
the circulation, it cannot undergo normal molecular changes, constitute an
elementary constituent of the blood, and promote secretion; because both
absorption and secretion are produced by the cellular formation and coales-
cence of the elements of the blood ; and they always bear a relation of direct
equivalence to the increase, decrease, or perversion of these molecular changes.

I have shown that the hepatic, renal, aud intestinal capillaries are more or
less replete according to the degree of portal congestion ; that repletion re-
tards absorption; that the different forms of the chemical force predominate
over those of the automatic, when this congestion exists; and that this pre-
dominance always decreases and alters, or augments and perverts absorption
and secretion in a proportion of equivalence to its degree of prevalence.
Hence it is an obvious fallacy to endeavour to restore the normal secretory
action of the hepatic, renal, and intestinal glands by the introduction of large
quantities of water into the alimentary canal. It is not only erroneous, but
often positively injurious, because the mechanical force of distension by an
elastic substance like water always favours absorption, while it proportionately
retards secretion. The capillaries of these glands are already too much dis-
tended by the aggregated blood ; why increase their distension by the intro-
duction of water ? The blood is so altered in quality, and so perverted in
elementary arrangement and chemical composition, that it cannot undergo
normal molecular changes. Will not the additional water introduced by ab-
normal absorption augment the perversion of the cellular mutations between
the elements of the blood by the superior intensity of an increased quantity ?

The sensation of thirst is urgent and agonizing. Will the drinking of
copious portion of cold water allay it ? The experience of every physician
answers that it will not; but, on the contrary, it will do a positive injury so
soon as the quantity is sufficient to distend the stomach, and, by the mecha-
nical force of its pressure on the mucous coat, accelerate its absorption, unless
it be happily ejected by vomiting, when the sufferer will feel joyously re-
lieved. ' A few moments' sweet repose will follow, when the sensation of
thirst will return, if possible, more agonizing than before. If copious draughts
of cold water afford no relief, if it often be a positive injury, what must be
done ? Do what pathology imperiously demands.
No. LXVIL— July 1857. 6

Casselberry, Water in Treatment of Fever.

[July

Neutralize, by molecular combination, the imperfectly combined oxygen of
the atmosphere in the blood by the proper use of water. How can this be
done? Appease the urgent thirst by the use of ice, broken into small pieces
and swallowed; and, when ice cannot be obtained, by small quantities of
cold water. Ice is more efficacious than water; it is much more slowly ab-
sorbed, and seldom or never does injury by distension. Its hydrogen is at
3rst feebly attracted by the imperfectly combined oxygen in the blood; only
a small portion is combined and forms a component part of the water of the
blood, while its oxygen has a feeble affinity for the carbon of the blood, in
consequence of the imperfect elementary arrangement of the molecular com-
bination of the carbon. As but a small quantity of the water of the ice is
absorbed and decomposed, its hydrogen neutralizes by combination an equally
limited amount of the imperfectly combined oxygen in the blood; and as
this oxygen is introduced in ample quantities at each inspiration, it follows
that its consumption should be commensurate with the quantity introduced.
Hence the necessity for the employment of water externally. The skin pre-
sents a surface of about fifteen square feet, and is liberally endowed with
absorbent and secretory glands. These have the same tissual endowments as
the same kinds of glands in the abdominal and thoracic organs, and associated
in intimate structural arrangement are sensitive and excito-motory nervous
branches. As pile upon pile increases the intensity of the electric current,
so endowment upon endowment augments the resistance of any particular
class of tissues to the force of a disturbing cause.

The mode in which water should be employed when the design is to re-
move imperfectly combined oxygen from the blood, is plainly indicated by
the anatomy and physiology of the skin. The cuticle is of firm structure,
and in a greater or less degree covered by an unctuous secretion, which resists
the introduction of water by absorption ; and, although it is penetrated by a
vast multitude of openings or pores, yet these are oblique, and often filled by
the unctuous secretion, commingled with other secretions and dust so as to
resist the admission of water.

Physiology teaches that cells are the agents the automatic nervous force
employs to produce molecular changes in the blood; that they generate and
develop, control and distribute animal heat and electricity; that a tissue is a
good or a bad conductor of these forms of matter according to the facility
and rapidity with which this force can produce molecular changes; and that
the capacity of every tissue for the generation, development, and distribution
of animal heat and electricity always bears a relation of equivalence to the
quantity and the degree of rapidity which the cellular changes of its nutritive
materials may transpire. Hence the fluids and the soft solids produce more
of these forms of foice or matter, and are better conductors of them than
the skin.

When it is designed to relieve the blood in the external capillaries from
aggregated heat and electricity, and imperfectly combined oxygen, it is there-

1857.] Casselberry, Water in Treatment of Fever. 79

fore necessary that the molecular changes should be augmented among the
elements of the blood, and that a conducting medium should be applied and
retained upon the skin for some time, that the requisite molecular mutations
may be produced in the cutaneous capillaries, and that the product of these
changes may be conveyed to the surface of the skin. Water is the best
medium for this purpose, because the imperfectly combined oxygen in the
blood has a strong affinity for its hydrogen, while its oxygen has an equally
strong affinity for the carbon of the blood. These reciprocal affinities accele-
rate the molecular changes of the elements of the blood, and thereby promote
the absorption and molecular combination of the water.

These molecular changes elaborate and arrange a portion of animal heat
and electricity, imperfectly combined oxygen, and some of the other effete
elements of the blood into the form of the secretory compounds of the skin,
and cause their removal to the surface,- upon which the animal heat and elec-
tricity are transmuted into mechanical force, by which sweat or any other
fluid is thrown off from the skin in the form of vapour. Authors teach that
animal heat is absorbed by the sweat or other fluids on the skin, and becomes
latent. This is a fallacy. There is no such thing as latent heat. If a new
form of force is not developed when animal heat and electricity are conveyed
to the surface of the skin, what causes sweat, or any other fluid, to assume
the form of vapour ? Nothing but mechanical force can, in this manner,
change the form of water. If this force be not developed by the conversion
of heat and electricity into mechanical force, how is it obtained ? For a
more extended consideration of this interesting subject, read an article I con-
tributed in the July number for 1855 of the American Journal of Medical
Sciences, in which I maintain the unity and mutual convertibility of all the
different forms of force or matter.

When it is designed to promote either the secretion of animal heat and
electricity from the external capillaries, or when it is desired to communicate
them to the different forms of the automatic nervous force in these vessels,
water is, therefore, the best medium; and it should be applied and retained
upon the skin for some time, because of the anatomical structure and physio-
logical functions which transpire in the cutaneous capillaries. This can be
done by means of folded sheets of domestic or linen, neatly and closely,
rolled around the person, wet in warm or cold water according to the indica-
tions to be fulfilled. Dry sheets should be carefully passed around the*wet
ones for the purpose of keeping the bedding dry. The atmospheric oxygen
should be carefully excluded; for when this has free access to the skin, it
disturbs and often prevents the reciprocal affinities of the different elements
for each other, and thereby arrests or retards molecular changes among the
elements of the blood. This is also the most favourable mode, of applying
water to the skin to promote its absorption; for it is retained upon the skin,
and a slight degree of pressure always favours absorption.

When pulmonary or portal congestion exists, especially when unattended

80 Cassel berry, Water in Treatment of Fever. [July

by inflammation, the domestic or linen should be carefully enveloped by
woollen blanket, which is a very imperfect conductor. This would, in a great
degree, exclude the oxygen of the atmosphere, retain the heat secreted from
the external capillaries, resist its conversion into mechanical force, support the
different forms of the automatic nervous force, favour the intensity of the
molecular changes of the blood, and thereby promote the secretion of an aug-
mented quantity of its effete elements by the depuratory glands of the skin.

The local use of water often contributes greatly to the comfort of the pa-
tient, and assists essentially in the fulfilment of important indications of cure
by consuming the imperfectly combined oxygen, by which the sensitive nerv-
ous branches are soothed; the excito-motory, tranquillized; and the auto-
matic, invigorated. During fever, especially when the skin is hot and dry,
three or four folds of linen, wet in cold water and laid upon the forehead,
often confers a boon of relief from agonizing pain and burning heat, and
thereby contributes essentially to restoring the diseased transformation of the
tissues to a normal state by eliciting the compensatory assistance of the sen-
sitive and excito-motory nervous systems. Relieved of the excess of the
imperfectly combined oxygen locally manifested by the sensation of pain and
burning heat in the external capillaries of the head, these nervous systems
impart increased intensity to the different forms of the automatic, augment
and accelerate the molecular changes of the blood, and promote the secretion
of additional quantities of the effete elements of the blood by the depuratory
glands. Congestion of the brain is often only simulative, not actual. This
state of the brain is often observed ; and I apprehend it is frequently mis-
taken in our Western alluvion districts, in which individuals are exposed to
all the atmospheric vicissitudes incident to a climate, whose physical geogra-
phy is chiefly composed of rich alluvial soil, clothed in forest trees and vege-
tation luxuriating in gorgeously exuberant foliage, variegated by winding and
often sluggish streams, stagnant bayous, and deep, silent lagoons, which, in
the summer and a part of the autumn, are exposed to a high temperature
during the day and a low temperature during the night, causing the atmo-
sphere to be more or less loaded with warm moisture during the former
period, and a cool, dense vapour during the latter.

The alluvion districts are irregularly girdled by undulating highlands of
clay soil underlaid by limestone. During August and September, these high-
lands are often dry and parched ; the atmosphere is hot and dusty ; vegeta-
tion languishes; foliage fades; the earth glows; the horizon gleams; forest
and fields seem a desolate waste. Pass upon the alluvion lands; mark the
contrast. The atmosphere is soft and moist ; vegetation smiles in exuberance;
foliage is robed in deep green attire; forest and fields seem to revel in gay
festivity. Evening approaches; darkness mantles the sky; a cool, dense
mist-vapour pervades the atmosphere. This physical condition of the atmo-
sphere disturbs the normal relation between the different forms of the auto-
matic nervous force; lesion of nutrition and secretion is produced; lesion of

1857.]

Casselberry, Water in Treatment of Fever.

capillary circulation follows; diseased transformation of all the tissues super-
venes; the blood is not normally introduced into the external capillaries from
the arterial branches by the molecular changes of nutritive, attraction ; it
aggregates in the portal venous system, in which the varied forms of the trans-
muted automatic nervous force prevail over the molecular changes of the blood,
produce diseased transformations of its elements, and cause their rearrange-
ment, coalescence, and chemical composition in accordance with the laws of
chemical combination.

Every attribute of the brain and spinal marrow are created perpetuate, and
impaired or destroyed by the molecular changes of the blood produced by the
different forms of the automatic nervous force. Hence the functions they
perform in the human organism always sustain an intimate relation of depend-
ence on the state of this force in its varied forms. When portal congestion
exists, and the different forms of the automatic nervous force are largely trans-
muted into those of chemical, the molecular changes of the blood in the arte-
rial, venous, and capillary systems are imperfect. These vascular systems in
the brain and spinal marrow constitute no exception. The molecular changes
of the blood in them partake of the imperfection. Hence the attributes of
the brain manifest every degree of lesion from greatly augmented and per-
verted sensibility to its complete suspension. As the molecular changes of
the blood become more and more diseased, the attributes of the brain are
more and more perverted, until sensibility becomes very obtuse or entirely
suspended.

This condition has often been mistaken for that of congestion. Why ?
Because of the stupor and insensibility? These are symptoms usually pre-
sent in both conditions of the cerebral vascular systems. A careful investi-
gation of all the symptoms, and a proper appreciation of the pathological
conditions which produce them, will reveal the diagnostic symptoms which
indicate the existence of congestion of the brain, and those which evince that
of an extreme perversion of the elements of the blood in the cerebral tissues.
It is of the first importance to ascertain conclusively, which of these condi-
tions is present; because some of the most potent agents in the treatment of
the one would be positively injurious in that of the other. How essential
that the diagnosis should be correct. Life depends upon it. The danger of
the patient is imminent. The most active means must be employed. Three
or four folds of linen or domestic wet in warm water should be applied over
the whole length of the spine. The legs and arms should also be enveloped
in the same. The linen or domestic should be frequently wet, that its tem-
perature may always remain as high as the patient can endure. Copious in-
jections of warm water should also be given every hour or two, and calomel
and opium administered every two or three hours. The necessity for conti-
nuing the use of water, as it is here directed for a considerable period, is
manifest, when we contemplate the cause of this pathological condition, the

Casselberry, Water in Treatment of Fever.

[July

mode in which it was produced, and the means by which the different forms
of the automatic nervous force may be restored to a normal condition.

In the April No. of this Journal for 1856, I have discussed the causes of
fever at considerable length ; and in this paper I have endeavoured to explain
the mode in which these causes influence the human organism ; what curative
indications may be fulfilled by the general use of water applied upon the skin;
the futility of drinking copious draughts of water to promote the secretory
depuration of the blood; but the vast importance of the subject will require
a further consideration of its curative agency, when locally employed.

Pathology teaches that the sensitive and excito-motory nervous systems
often lend a compensatory aid to the automatic ; and that without them the
latter could not maintain all the attributes of the human organism; for
although the automatic elaborates and appropriates the material to sustain and
perpetuate these; yet it must employ one of them as an agent to bring it into
relation with the external world, and the other for the production of muscular
motion. The automatic supplies the creative, sensitive, and motive power;
the sensitive and excito-motory are endowments which it employs for the
manifestation of the higher and nobler attributes of intellectual beings.
Hence all these nervous systems maintain a relation of mutual dependence
on each other. They all perform functions indispensable to the conservation
of the human organism. The imperative necessity for eliciting the reciprocal
aid of these nervous systems in simulative congestion of the brain is, there-
fore, obviously manifest. How can this be best accomplished ?

The automatic nervous system is endowed with the creative and distinctive
agencies of the organism. These are no longer equal to each other; the de-
structive predominates. How can this predominance be subverted? The
molecular changes of the blood are not normal. The blood is becoming more
and more contaminated by effete elements. Normal nutritive elements can-,
not be introduced. Those which exist must be depurated. The depurative
glands of the skin and lungs have sensitive and excito-motory nervous
branches in intimate relation with them, while those of the liver and kidneys
are without those efficient endowments which always give increased intensity
to the different forms of the automatic nervous force. This combination of
nervous endowments, which are ever ready to compensate for the deficient
functions of each other, bestows upon the tissues to which they are distri-
buted a much more durable resistance to the force of a disturbing cause than
that possessed by those which are endowed with automatic nervous branches
only.

The anatomical relation which the pulmonary and cutaneous vascular sys-
tems sustain to the portal venous system, always causes them to contain less
than a normal quantity of blood, where, from auy cause, an accumulation of
blood takes place in this venous system. The blood in the cutaneous blood-
vessels is nearer maturity than that in the internal organs; for, in these it is
in every state, from irrcipiency to maturity; while, in the former, the mass

1857.]

Casselberry, Water iu Treatment of Fever.

approaches maturity ; and, as a consequence of this, the different forms of
the automatic nervous force in the external bloodvessels offers greater resist-
ance to the force of a disturbing cause. From the superior nervous endow-
ments of the external tissues; from the anatomical relation of the external
bloodvessels to those in the internal organs, and from the diminished quantity
and approaching maturity of the blood in them, the external tissues do not
generally suffer as much by a disturbance of the different forms of the auto-
matic nervous force as those of the internal organs. The state of the blood
in the external bloodvessels ; the intimate relation of the cutaneous depura-
tive glands with sensitive and excito-motory nervous branches; the compen-
satory relation of functions between the different nervous systems; and the
immense expanse of the skin, conspire to make this the most fertile and pro-
ductive field in which remedial agents can be employed.

Why has it been so much neglected ? Because remedial means have not
been so used as to elicit the curative agencies of the component tissues of the
skin.

Bathing was employed in the earliest ages of antiquity, and it has ever
continued to be held in high estimation among many nations. But the pro-
per employment of water as a remedial agent has not sufficiently engaged
the attention of the medical profession. Bathing is conducive to cleanliness,
and elicits, in some degree, the compensatory aid of the sensitive and excito-
motory nervous functions. But the depuration of the blood, when there is
any considerable disturbance of the different forms of the automatic nervous
force among its elements, requires the continued application of water for a
certain period, so as to influence the molecular changes of its elements, pro-
mote their formation, accelerate their rearrangement, augment their coale-
scence, and favour their separation into nutritive and effete elements.

This evinces the necessity for the continued application of water along the
course of the spine, when the design is to elicit the compensatory aid of the
sensitive and excito-motory nervous branches in the depuration of the blood,
when there is extreme perversion of its elements. For the skin over the
spine is largely endowed with these nervous branches in a comparatively
favourable condition to lend their assistance; the external tissues are more
liberally endowed with means of resistance to the force of a disturbing cause
than the internal organs; the blood in them, although diminished in quantity,
is nearer maturity than in these organs; the different forms of the automatic
nervous force in the external tissues, therefore, soon manifest increased inten-
sity when water is applied and retained upon the skin.

The molecular changes of the blood in the minute capillaries about the
origin of the excito-motory nerves, and that of the sensitive nerves which
arise from the medulla oblongata, are increased in intensity, augmented in
quantity, and altered in quality; the elements of the blood are formed and
transformed, coalesced and rearranged with multiplied celerity ; the nervous
roots and adjacent tissues are supplied with additional quantities of nutritive

Casselberry, Water in Treatment of Fever.

[July

material ; more powerful reflexed actions are transmitted ; the compensatory
aid of these nervous systems begins to be manifested. Now apply a folded
napkin, wet in hot water, over the epigastric region; inspiration is freer; an
increased quantity of oxygen is absorbed, and an additional quantity of carbon
is secreted by the augmented molecular changes of the blood in the pulmonic
capillaries. The mechanical force of the muscular action of the heart and
arteries soon receives increased power from the altered quality of blood con-
veyed to their muscular tissue by their nutritive arteries, and an augmented
quantity of blood is propelled and conducted to the external capillaries, in
which the different forms of the automatic nervous force have received increased
intensity by reflexed action. This intensity may be greatly augmented, and
the reflexed action made much more conducive to its integrity by enveloping
the arms and legs in three or four double of linen or domestic, wet in hot
water, and retained for at least half an hour; because the imperfectly com-
bined oxygen of the atmosphere, conducted along with the blood into the
external capillaries, would then attract the hydrogen of the water, combine
with it, and constitute water, which would be removed and deposited on the
skin in the form of sweat; while the carbon of the blood would combine with
the oxygen of the water, evolve heat, and be removed in the form of carbonic
acid gas. Freed of the consuming force of the imperfectly combined oxygen,
the sensation of pain and burning would not be experienced; the compensa-
tory force of reflexed action would be more manifest, because it would be con-
sumed chiefly by imparting increased intensity to that of the different forms of
the automatic, and not by the manifestation of perverted sensation and in-
voluntary muscular motions. It would, therefore, contribute to the molecular
changes of the blood, and accelerate its depuration in the external capillaries
by favouring absorption and promoting secretion. When we review the
immense extent of the skin, when we contemplate the magnitude and wisdom-
of its endowments, we can appreciate the advantages of its agency in the
restoration of the organism, when the varied forms of the automatic, nervous
force are disturbed and ready to invite the oxygen of the atmosphere into the
citadel of life. The arms and legs may be constituted into four fields for the
subjection of the rebellious elements of the blood ; the commanding officer
must be selected and nurtured in the cerebro-spinal region; while new recruits
must be trained and mustered into the service of the organism along the course
of the alimentary canal.

Copious injections of water should never be omitted in the treatment of
fever, as it prevails in the southwest; because there is always more or less
biliary derangement; and there is no more efficacious means for the removal
of bile and other perverted secretions from the alimentary canal. When the
functions of the stomach are so perverted that it will not retain medicine,
copious injections of water often have a very salutary effect by removing the
altered secretions and other fecal matter from the bowels, by which they
promote the tranquillizatiori of the disturbed reflexed actions of the sensitive

1857.]

Casselberry, Water in Treatment of Fever.

and excito-motory nervous systems. This state of the stomach often consti-
tutes a most troublesome complication in the treatment of fever. It is fre-
quently observed in persons who suffer of fever during the hot days of August
and September. Copious injections of warm water should be frequently
employed; a towel, wet in cold water, should be folded and laid over the
entire epigastric region; three or four folds of domestic or linen about six
inches in width, wet in cold water, should also be applied over the whole
length of the spine and retained for an hour or two ; a folded napkin, wet in
cold water, may often be advantageously applied over the larynx, especially
when the vomiting is persistent. The application of water, in this manner, is
of peculiar advantage in controlling the persistent vomiting of children during
the period of dentition, because of its efficacious influence in tranquillizing the
reflexed actions which the evolution of teeth so greatly augments. Both the
colliquative diarrhoea and the persistent vomiting which so frequently afflict
children during this tender period are chiefly dependent upon, and often are
perpetuated by, this perverted nervous action.

Unless the individual is of intemperate habits the use of water, as here
directed, seldom fails to tranquillize the stomach, remove the perverted secre-
tions from the bowels, and prepare the organism for the favourable reception
of other remedial agents.

Dr. Henry F. Campbell, of Augusta, Ga., has published two very able and
interesting essays on the pathology of reflexed nervous actions during denti-
tion and during fever, with certain complications. These are invaluable con-
tributions to medical science, and they will serve as beacon lights to every
pathologist {South. Med. Journ., for June, 1850, and Trans. Amer. Med.
Ass., for 1853.)

After the bowels are freely moved and the stomach nearly tranquillized,
great advantage may often be derived by enveloping the patient in sheets
wet in cold water. Dry sheets should be rolled neatly around the wet ones,
and the whole allowed to remain until the sensation of heat and pain is re-
moved. From half an hour to an hour will generally be sufficient to produce
this effect. The prompt and judicious administration of quinine will generally
prevent the recurrence of these symptoms. During the forming state of fever,
and often during the first day or two of its progress, obstinate constipation is
frequently observed. For the removal of this complication large injection's of
warm water are peculiarly efficacious, because they neither offend the stomach
nor delay the administration of other appropriate agents. They promote the
dejection of the accumulated fecal mass and depraved secretions, and contri-
bute to the normal restoration of the perverted nervous functions.

Diarrhoea is a very troublesome complication of fever, because it greatly
promotes the debility consequent upon the fever, causes nutritive material to
be voided before it is assimilated, and renders remedial agents much less effica-
cious. It is often present during the progress of a fever; but it is much more
frequently observed during the protracted continuance of a fever as it prevails

Casselberry, Wafer in Treatment of Fever.

[July

in our alluvion river bottoms, with a vast multiplicity of complications. No
remedial agent is more efficacious in the removal of the cause of this diarrhoea
than large injections of cold water. These should generally be employed
twice or three times a day ; but they may often be advantageously used after
each evacuation of the bowels. The long continued recession of the blood
from the external capillaries and its persistent lodgement in the portal venous
system, contribute to the perversion of the functions of the vast multitude of
absorbent and secretory glands along the course of the alimentary canal, be-
cause of its accumulated quantity and altered quality in the intestinal capil-
laries; while the augmented amount and perverted quality of the biliary
secretion is conveyed to the organizing force of many of these glands ; but
this force is so diminished in intensity by the altered quality of the blood in
these glandular capillaries, that when the perverted biliary secretion approaches
the glands its nascent formative condition is transmuted, and the constituents
of the food, which it was forming into elements of blood, are attracted, com-
bined, and dejected with this altered and perverted fecal compound. This
constitutes what is commonly called limitation of the mucous membrane of
the bowels.

When we see the vast number of absorbent and secretory glands in the
mucous membrane of the alimentary canal; when we contemplate the import-
ant and multiplied functions they perform for the conservation of the organism,
we can easily appreciate the immense advantages of their constant and careful
protection, and of their earliest possible relief when disturbed in functional
duty.

In the treatment of this complication of fever I greatly prefer cold water
injections to all the much commended astringents, because they seldom favour
the production of other and often more dangerous complications, as some
astringents frequently do; and they promote the establishment of a state of
the organism favourable to the administration of quinine and other necessary
remedial agents.

Bathing is often a valuable therapeutic agent to harmonize the relation
between the nervous systems when no considerable degree of diseased trans-
formation of the tissues exists. It may, therefore, be often advantageously
employed in the forming state of fever, or during the convalescence of a
patient.

1857.] "Warren, Influence of Pregnane]/ on Development of Tubercles. 87

FISKE FUND PEIZE ESSAY.

Art. IX. — Does Pregnancy accelerate or retard the Development of Tubercles
of the Lungs in persons predisposed to this Disease? By Edward War-
ren, M. D., of Edenton, North Carolina. The Dissertation to which the
Fiske Fund Prize was awarded, June 4, 1856. 1 (Published by request of
the Rhode Island Medical Society.)

Chap. I. § 1. — "Similia, similibus curantur," is the maxim of Hahne-
mann and his followers. " Contraria contrariis curantur" is the doctrine of
Hippocrates and of those who recognize hiin as their leader. According to the
teachings of one, two affections of a like nature cannot exist at the same
time in the organism; and the most effectual method of destroying a sponta-
neous morbid condition, is to superinduce an artificial state of a similar cha-
racter. The other affirms, that dissimilar conditions only are incompatible,
and that disease is relieved most completely and certainly by developing in
the system a state opposite and antagonistic to that already existing. Ho-
moeopathy bases its theories upon the doctrine of "similitudes:" Allopathy
finds the "fons et origo" of its principles in the great law of " antagonism"
which is impressed on all morbid phenomena.

If the utter falsity of this doctrine of " similitudes" were not acknowledged
by a vast majority of scientific men, whose daily experience but confirms
their logical deductions respecting its real character, it might be important,
in this connection, to adduce the testimony of the ablest advocates of Homoeo-
pathy in proof of the impracticability of the system, and to demonstrate the
contradictions ana inconsistencies of its fundamental principles.

But these false doctrines have already reached the climax of their glory;
the world begins to realize that it has been deluded long enough by the
maxims of this mistaken philosophy; the period for discussion has gone by,
and it is only necessary to make a plain statement of the whole matter, and
then to leave it to the common sense of mankind, in order to secure the
complete overthrow of this pernicious system.

At Leipsic, which has been the head-quarters of Homoeopathy, the only
hospital devoted to that system contains but six beds, and all of these are

1 The Trustees of the Fiske Fund, at the annual meeting of the Rhode Island Medi-
cal Society, held at Providence, June 4, 1856, announced that they had awarded' to
the author of the dissertation bearing the motto —

" Quifugit molam, farinam non invenit,"

The premium of one hundred dollars, by them offered for the best dissertation on
the following subject, viz: "Does Pregnancy accelerate or retard the Development of Tu-
bercles of the Lungs in persons predisposed to this Disease?"

Upon breaking the seal of the accompanying packet, they ascertained its author
to be Edward Warren, M. D., of Edenton, North Carolina.

Ariel Ballou, M. D., Woonsocket,

Hiram Cleveland, M. D., North Providence,

Isaac Kay, M. D., Providence,

Trustees.

J. Aug. Arnold, M. D., Providence,

Secretary of the Fiske Fund Trustees.

88 "Warren, Influence of Pregnancy on Development of Tubercles. [July

not usually occupied. In Paris, M. Andral put it to the test of experience
in one of the general hospitals, and the result was a total failure. He treated
one hundred and forty patients in the presence of the homoeopathists them-
selves, adopting every requisite care and precaution, and yet in not one instance
was he successful. In Russia, the Grand Duke Michael invested a G-errnan
homoeopathist with full powers to test its merits, and in two months the ex-
periment was pronounced unsatisfactory by the government, and discontinued.
In Naples, a trial was made by the royal order, by which it was established,
not only that homoeopathic treatment produced no effect on disease, but that
it was positively injurious — for the reason, that it prevented the employment
of remedies by which the patients might have been cured. In London, there
are, at present, but two homoeopathic hospitals, one of which is about closing
for want of funds, and the other is in a declining state. Thus has the sys-
tem of Hahnemann proved a failure when tested practically, and is now
everywhere on the decline.

Theoretically, it has not been more successful, as must be admitted by
every unprejudiced mind. The homoeopathists have failed to demonstrate
either that medicinal powers do produce an artificial malady, similar to the
natural affection ; that the organism only remains under the influence of the
medicinal disease; that the artificial disease is of short duration, or that all
the effects can only be produced by selecting an agent which produces results
similar to the symptoms; and hence, their doctrines have not only been im-
pugned by Rau, Shroen, and Griesselich, but repudiated as illogical and
visionary by the most intelligent observers throughout the world.

The doctrine of Hippocrates has its foundation in reason — embodies the
plain, practical, and logical view of the subject, and is sustained by the expe-
rience of a vast majority of the most scientific men in every country. Upon
it has been reared the superstructure of modern medicine; and to it belongs
the glory of nearly all the triumphs which have marked the progress of the
healing art from the days of its founder, down to the present time. The
principle, that " like causes produce like effects," and the proposition which
stands in correlation to it, are recognized in every department of science, and
by all classes of observers. So universal is the acceptation of the truths thus
imbodied, that they have become axioms in themselves, and the tests whereby
the merits of any system may be determined. Homoeopathy rejects these
propositions — repudiates the principles involved in them, and assumes that
Nature, in her therapeutical operations, acts upon another and an entirely
contradictory plan. Their explanations of the great processes now under
consideration, would lead them, if strictly adhered to in the practice of medi-
cine, to increase the congestion of the brain in apoplexy; to accelerate the
circulation in fever; to restrain hepatic action in torpor of the liver; and to
induce a condition of debility, stagnation, and impoverishment in the systems
of those predisposed to phthisis — which would be as reasonable as for the
sailor to attempt to lighten his ship by adding to her cargo, or for the en-
gineer to relieve the strain upon the boiler of his engine, by the constant
generation of steam. This system, to be true, must make the axioms alluded
to, false ; and as the idea of falsity is utterly precluded by the very definition
of the term, it follows that homoeopathy is illogical in its fundamental prin-
ciples. Disease can be nothing more than a manifestation of certain pheno-
mena, which depend upon the existence of some principle, different in its
esseuce and operation from that agency by which the organism is maintained
in its normal state. It consists in the presence of a series of effects, which
are the results of the action of a particular cause. This cause operates, and

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 89

these effects are produced in consequence of some alteration of the natural
condition of the system, whereby a state is developed favorable to the action
of the one, and the manifestation of the other. Hence, we have three ele-
ments essential to disease : —

1. An altered condition, resulting from the operation of some general in-
fluence or cause, unlike the normal or healthy condition and favorable to the
action of a particular cause.

2. A cause distinct alike in its intrinsic character, and in its ultimate
effects, and operating in a peculiar manner.

3. Effects, or symptoms, which take their character from the peculiar
agent which has called them into existence, and from the manner of its
action.

In some affections, as those which are contagious and infectious, this gene-
ral and this immediate cause are combined, or so intimately associated, that
they cannot be distinguished ; whilst in the remainder, such as typhoid fever,
phthisis, &c, they are not only separated, but easily recognized and cogniza-
ble. Now, it is manifest that the first step towards recovery, consists in an
alteration of that original morbid condition, by which the particular cause
has been enabled to operate in the production of its legitimate effects or
symptoms, and hence it becomes a matter of the greatest importance to effect
that change promptly and effectually. The continued action of this particu-
lar cause, or a similar one, implies a continuance of the same original condi-
tion— whilst the operation of a dissimilar agent, demands the existence of a
different state, and demonstrates that it has been superinduced. But effects
or symptoms are the only means whereby causes make themselves known,
and consequently, it is only when these phenomena are unlike those which
presented themselves in the first instance that any positive evidence is afforded
of the commencement of the curative process. Thus it becomes evident, not
only that' the doctrines of Hahnemann are intrinsically false, but that the
principles of Hippocrates are logically correct and entirely consistent with
the laws of Nature.

Whatever cause, then, has a tendency to the production of a certain set of
phenomena, is opposed, resisted, or restrained by that agent which produces
dissimilar results, and hence the manifestation of these opposite effects or
symptoms, is an evidence that an antagonism has been produced and that the
curative process is in operation.

Having thus considered the nature of the law of antagonism as enunciated
by the oracle of Cos, and demonstrated its logical truth and practical applica-
bility, I shall proceed to examine into the nature of phthisis, for the purpose
of showing that pregnancy develops in the system a condition directly antago-
nistic to that state which favours and accelerates the deposition of tubercles.

This investigation necessarily divides itself into three heads, thus : — *

1. A consideration of the tubercular diathesis.

2. An inquiry into the nature of tubercle.

3. An application of the rules respecting disease already established.

Whatever differences of opinion may exist in regard to the real nature of
tubercle, all, at the present day, agree that it is preceded by a general morbid
condition of a peculiar character. This condition has been denominated "tu-
bercular cachexia," by which is implied the existence of certain abnormal
symptoms, indicative of an unhealthy state of the economy, and a predispo-
sition to the deposition of tubercles in the lungs. This diathesis connects
itself both with the general system and the organ in which the deposit is
made, and hence it is important to examine it in its twofold relations.

90 Warren, Influence of Pregnancy on Development of Tubercles.

1. As regards the System at Large.1 — The ultimate construction of tissues
consists in minute cell-formations and cell- germs, which are capable of repro-
duction so long as they are supplied by the blood with certain organizable
materials. In the normal state there is a constant disintegration and reproduc-
tion of these cells, and an equable and reciprocal balance between the processes
by which they are performed, which constitutes health in the economy. When
the supply of pabulum is diminished in quantity or altered in quality, this
natural equilibrium is destroyed, and disease results as a necessary and natural
consequence. The plasma of the blood is the organizable pabulum which plays
this important part in the economy, and hence the circulating fluid becomes
the source of formative supply or deficiency to the cell-germs and the means
whereby structural degeneration or healthy action is secured. When blood
possesses its natural elements in their normal ratio and proper character, the
conditions essential to health are complied with, and all morbid action is ne-
cessarily precluded. On the other hand, when changes have taken place in
the blood, by which its various constituents are reduced below the normal
standard, either completely, partially, or in quality, then the function of assi-
milation is interrupted, and a condition of disease develops itself in the system.
The blood is supplied to the body through the agency of nutrition, and when
that function is properly performed, the circulating fluid is rich in formative
material, the tissues receive their due supply of organizable pabulum, and the
normal state of the organism is maintained intact. But if this process is
interfered with, the sanguiferous constituents are not produced in their equable
and natural relation, the fibrinous plasma ceases to be properly elaborated,
the red globules decrease in quantity, the albuminous element becomes ex-
cessive, and a condition of disease is developed throughout the economy.

To understand the manner in which the function of nutrition is interfered
with, it is necessary to refer to the successive changes which characterize that
process under ordinary circumstances. They are the following: —

1. The receipt of organic matter in the stomach.3

2. The transformation of this matter into albuminous and oily compounds.

3. The absorption of these by the mucous membrane, and their union into
elementary nuclei and cells.

4. The transformation of these, first, into chyle corpuscles, and secondly,
into blood.

5. The abstraction of the tissues of these materials which are essential to
their nutrition.

Now, it is evident that as all these successive steps are essential to a proper
performance of the function of nutrition, an interruption of either will inter-
fere with all those changes which succeed it, and thus derange the whole pro-
cess. In order to ascertain where the interruption has commenced, when any
derangement exists, it is necessary to begin with the last effect produced, and
to trace the morbid actiou through each successive step, until that one has been
reached wherein the primary departure from the normal standard originated.
In this tubercular diathesis the blood is so altered in quality that it fails to
present to the tissues the organizable element which is their pabulum, and
hence enervation, emaciation, and derangement of function are the symptoms
which characterize this peculiar cachexia. Of all the tissues of the body, that
which is composed of fat-globules, and known as the adipose, suffers most, and

1 See Valentin, Berlin, 1834; also, Wagner, Leipsic, 1839; Shwann, Berlin, 1839;
Schleiden, Paget, Meckel, Gairdner, and others.

2 Dr. Arclnson, Berlin.

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 91

disappears with the greatest rapidity. This fact accounts for the extreme
meagreness of phthisical patients, and clearly indicates such a derangement
of the function by which fatty elements are produced, as really amounts to
its complete suspension. We are thus carried back to that step in the process
of nutrition by which chyle is formed, and therein discover certain abnormal
changes, which, whether they depend upon any alteration or defect in the che-
mical and physical actions by which they are preceded, or on some other cause,
are amply sufficient in themselves to account for the deterioration of the cir-
culating fluid, and to explain all the phenomena which accompany and distin-
guish the tubercular cachexia. The experiments of Tiedeman and Magendie,
as well as the chemical deductions of Prout and Liebig, clearly demonstrate
that a proper admixture of albuminous and oleaginous elements is essential to
healthy nutrition ; and if healthy chyle be examined, these two principles —
fat and albumen' — will be found to constitute its essential elements ; so that
any influence which prevents the existence of either, or the proper admixture
of both, impoverishes that fluid itself, and, as a consequence, produces a de-
terioration of the blood which is formed from it. As the globules of fat cannot
enter into the system without being altered, and as an examination of the liquid
found in the lacteals discloses the fact that the oleaginous elements have been
reduced to a state of infinite division, it becomes evident that this alteration
in their character is essential to healthy nutrition, and that there is some organ
whose normal function it is to bring fatty materials into this state of emulsion.
To 3V1. Bernard belongs the credit of having discovered the manner and means
of this transformation. He forced a rabbit to eat nothing but meat, and then,
having opened the abdomen, he discovered that the absorbent vessels of the
small intestines contained a limpid fluid for the distance of twelve inches below
the pylorus, and that from that point they were white, and contained the same
fluid as that which is found in the lacteals of the human subject, and in the
dog throughout the whole extent of the duodenum. From this fact, and the
additional reasons that in man the ducts of the liver and pancreas enter the
duodenum together, near the inferior extremity of the stomach, and that in
the dog one of the ducts of the latter organ empties with the duct coming
from the former, M. Bernard concluded that it was the secretion from the pan-
creas that made the milky fluid which presented itself in the lacteals, and
which depended upon the reduction of fat-globules to a state of emulsion for
its peculiar appearance. As a means of testing the truth of this inference,
he mixed pure pancreatic juice with oil, butter, tallow, and many different
varieties of fat, and ascertained that it formed an emulsion with them all,
resembling in every respect the chyle extracted from the mesenteric lacteals,
and capable of retaining its peculiar character for an indefinite period. He
then tried bile, saliva, gastric juice, serum, and the cephalo raehidian fluid,
without producing any other effect upon oleaginous matter than the formation
of a mechanical mixture, which returned to its original state in a few moments.
In addition to these external experiments, he made others upon the internal
organs, by which his first conclusions are positively substantiated. They are
thus described by Dr. Donaldson :* —

"After keeping a rabbit fasting for some time, he gave it a full dose of twenty
grammes of fat, and, allowing sufficient time for it to be pushed down in the
intestine, he killed the animal in three hours, and found the absorbents nearly
empty to the point of insertion of the pancreatic duct, whereas below that they
were distended with white chyle. In the intestinal cana), above the duct of the
pancreas, there was some melted fat which was unaltered in aolour, but below

1 American Journal of the Medical Sciences, 1851.

92 Warren, Influence of Pregnancy on Development of Tubercles. [July

it was seen white emulsion, corresponding to that contained in the lacteals. His
next essay was in tying the pancreatic duct of another animal of the same spe-
cies before giving the oil, and, on opening the abdomen after the same lapse of
time, he found the lacteals free from chyle, and the oily matters undigested in
the intestinal tube passing down to be thrown off in the excrement. On putting
a ligature around both the pancreatic ducts of a dog, he had the same result."

From the facts thus clearly established, he drew the inevitable conclusion
that " the digestion of fatty matters was the peculiar office of the pancreas."
This deduction has also been substantiated by the observations of Barreswil,
Colin, Lassaigne, Dumas, and others, and is now generally received and ad-
mitted by the medical profession.

In tubercular cachexia, this digestion of fatty matter is prevented, and
hence, the demand upon the tissues for the oleaginous materials deposited in
them, and the general emaciation which immediately results to the patient.
An interference with that process by which fat is emulsionized and made
assimilable, must depend upon some alteration in the pancreatic fluid, or
derangement of the organs by which it is secreted. Bennett believes that
this result is due to some vitiation of the fluid, and explains the phenomenon
in the following manner: "The peculiarity of phthisis however, is, that an
excess of acidity exists in the alimentary canal, whereby the albuminous
constituents of the food are rendered easily soluble, whilst the alkaline secre-
tions of the saliva and pancreatic juice are more than neutralized and rendered
incapable either of transforming the carbonaceous constituents of vegetable
food into oil, or of so preparing fatty matters introduced into the system as
will render them easily assimilable." That this acidity1 exists can be easily
established, either by appealing to authorities or referring to the experience
of every practitioner of medicine, and that it increases the solubility of the
albuminous constituents, is perfectly evident'; but its effect upon the pan-
creatic fluid is involved in much doubt and difficulty.

If this development of acid were the first link in the ^feain of morbid phe-
nomena, nothing would be easier than to counteract it by the employment of
appropriate neutralizing remedies. By the use of proper alkaline agents,
this condition of acidity — by which the function of the pancreas and the pro-
cess of healthy nutrition are arrested — could be easily destroyed, and the
tubercular diathesis removed without difficulty or delay. It is well known,
however, that no morbid state is more obstinate or persistent, than that which
is characterized by a disposition to the formation of tubercles in the pulmo-
nary parenchyma, and that the only treatment from which a successful result
may be anticipated in this cachexia, consists in the constant employment of
appropriate tonics in connection with certain general remedies. This is an
important fact, as will he demonstrated in another part of this paper, because
it indicates that the source of the disorder can be traced to the nerves, and
associated with the vital forces of the economy.

Again — if the improper digestion of oleaginous elements depends upon
the alteration effected in the pancreatic fluid, in consequence of the develop-
ment of this excessive acidity, then the employment of substances rich in
acidulous constituents, would predispose to this particular diathesis. An
indication would thus present itself in the treatment of phthisical predispo-
sition, which would demand the constant abstinence from those alimentary
elements which contain acids, and the avoidance of acids as remedies under
every circumstance which connects itself with this particular cachexia. This
would involve us in the absurdity of attempting to prevent the invasion of

1 Clark, Williams, Wood, and others.

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 93

phthisis by the development of the circumstances most favourable to the
existence of scorbutus, and the rejection of remedies standing pre-eminently
forth in the list of tonics, which are universally admitted to be most useful
agents in the management of the tubercular diathesis. If the above expla-
nation be correct, it would follow as a matter of course, that with those per-
sons who habitually use a large quantity of food, rich in acidulous elements,
phthisis would present itself most frequently; and hence, in the tropics,
where fruits are constantly ingested, cases of this affection would be most
uumerous — whilst the very opposite of this is true, as is universally admitted.
Emaciation does not necessarily ensue where there is excessive acidity, for
Trousseau has long since reported and explained many cases of dyspepsia in
which this feature was particularly prominent, whilst the fatty tissues re-
mained intact, and a plethoric condition of the system was maintained. It
is well known also that many persons suffer habitually from an inordinate
development of acidity, without being materially affected in their general
health, and manifesting any waste of tissue or diminution of rotundity.

The idea of the necessity for the preservation of alkalinity in the pancre-
atic fluid, is not original with Bennett. M. Mialhe1 maintained that alkalies
are the great solvents in the animal system, and that their presence in the
secretion of the pancreas, is the cause of the formation of that emulsion,
whereby fatty matters are made digestible. M. Bernard, however, has con-
clusively demonstrated that the explanation is utterly false, and the question
of its paternity is consequently rendered an unimportant one. In the first
place, he showed that the natural acidity of the mucus would be sufficient to
change the reaction of the juice as it issues from the pancreatic duct; and in
the second, he proved that the fluid acts even in the acid mixture, which of
course settles the question immediately and definitely. t It follows, then, from
these considerations, that the improper digestion of the oleaginous elements
of the food does not depend upon an alteration in the pancreatic fluid, after
it has been secreted, and that Bennett is entirely mistaken in his expla-
nation of the phenomena. If the fluid be not in fault in this manner,
then the pancreas must be the source (intestinal) from whence originate
these influences, which so materially interfere with and modify the digestive
process. They must either produce an altered and unhealthy fluid or secrete
the natural one in a diminished and insufficient quantity. Either supposi-
tion will account for the condition of things which results in the intestine,
and to the system at large, and it is unnecessary in this connection to attempt
to determine which explanation is the correct one. It is manifest that there
is some defect in the secreting powers of the organ, by which a proper per-
formance of its functions is prevented, and from which all the morbid pheno-
mena originate. This organic difficulty must depend, either upon some local
cause, as inflammation, congestion of its substance, or some general one con-
necting itself with that nervous influence distributed to it, by which its
normal actions are directed or controlled. The symptoms which distinguish
the operation of the first series of causes, are described by all writers on
pathology, and can be easily distinguished by every observer. As these do
not exist, and as post-mortem examinations fail to discover those organic
lesions which are indicative of inflammation, congestion, &c, it follows neces-
sarily that the derangement in question results from the action of the general
cause alluded to above.

The influence of the nervous system on the secreting powers of the various

1 Meraoire sur la Digestion et 1' Assimilation des matieres albuminoides, &c, 1847.
No. LXVIL— July 1857. 7

94 Warren, Influence of Pregnancy on Deuelopment of Tahercles. [July

organs, has long been maintained by pathologists, but it was reserved for the
learned and laborious Bernard to explain aud demonstrate it fully. By a
series of most ingenious and convincing experiments, he has eliminated the
nature of the offices imposed on the various classes of nerves, and showed
conclusively, that the trophic system controls and presides over secretion.
He traced out the particular nerve distributed to different organs, and suc-
ceeded in promoting and arresting the production of the fluids appertaining
to each gland, by alternately increasing and diminishing the amount of nerv-
ous force with which it is supplied. From these experiments, and on
account of the reasons mentioned above, it is fair to conclude, that the im-
proper digestion of oleaginous elements, upon which emaciation depends in
the tubercular cachexy, results from the fact, that the normal amount of
nervous force is not conveyed to the pancreas; and hence, it is evident that
the primary lesion connected with phthisis, is to be found, not in the digest-
ive apparatus itself, but in the nervous system which presides over it. This
view of the subject is not only the one which best explains the phenomena
characteristic of the tubercular cachexy, but is sustained alike by an exa-
mination of the causes which induce this particular diathesis, and a reference to
the remedies essential to its relief.

The causes of phthisis may properly be divided into two classes: (1.)
General Causes. (2.) Special Causes.

(1.) General Causes. — Among the most prominent of these is hereditary
predisposition. Since Hippocrates declared "Ex tabido tabidus," all wri-
ters, with two exceptions, have repeated, that consumption is hereditary.
Louis contends that phthisis is not ordinarily inherited, and Piorry affirms
in his second work, that it is only so in one case out of ten. It is no
longer believed that the disease transmits itself by means of a particular
virus, as was once supposed, but its reproduction is attributed to the develop-
ment in the child of the same qualities, mental and physical, as those which
distinguished its parents. It is evident that a predisposition which depends
upon the existence of a mental quality, must connect itself with some abnor-
mal condition of the nervous system ; since it is only through the medium of
the nervous mass, that mind manifests itself in its varied and multitudinous
relations. The very fact that phthisis is an hereditary affection, is prima
facie evidence, that its origin can be traced to the nerves; for it is notorious
that those diseases which are caused by interruptions in the transmission of
nervous force, or an improper development in the great generating centres,
are more generally inherited than those involving other tissues of the body,
or resulting from the operation of different influences in the economy. Thus,
insanity descends from sire to son through many generations — whilst convul-
sions, epilepsy, hysteria, chorea, and various other affections of the nervous
system are the fatal heirlooms in many families.

The constant use of improper aliments also occupies a conspicuous place in
the catalogue of causes whereby consumption is produced. Now it is evi-
dent, if, when they are originally taken in the stomach, a condition of health
exists which secures their proper digestion and assimilation, the amount of
nutritious matter contained in them would be appropriated by the tissues,
and, although emaciation and enervation would result, they could only indi-
cate the fact that assimilable elements had not been ingested in sufficient
quantity. Until a specific derangement in the digestive process is effected,
the tubercular cachexia cannot exist, and it is only because of the induction of
a distinct morbid alteration in the system that this peculiar diathesis is de-
veloped. The various tissues of the body require the constant supply of an

1857-] Warren, Influence of Pregnancy on Development of Tubercles. 95

organizable material of a certain quality in a definite quantity, and without this
supply, a change is effected in their organic character, and an alteration oc-
curs in their manner of executing the particular function for which they are
designed. Nervous tissue is distinguished not only by its intrinsic delicacy
of structure and excessive sensibility, but also for the importance of its func-
tions and the variety of its relations; and when the material habitually con-
sumed is bad in quality, aud diminished in quantity, it, as a matter of neces-
sity, first feels and manifests the operation of this debilitating and morbific
influence. In a word, the tubercular cachexia is developed thus : —

There is improper material taken in the stomach ; enervation and emacia-
tion ensue ; the nervous system feels most sensibly the withdrawal of appro-
priate pabulum ; a proper supply of nervous force does not reach the organs
of secretion connected with the digestive apparatus; torpor is produced; a
positive interruption of the process results, and a condition of disease is de-
veloped.

M. Fourcault and Dr. Beddoes think that the skin is primarily affected,
and in such a manner that its functions are interfered with, whilst the lungs
become secondarily involved, either through sympathy, or in an effort to
eliminate the elements which should have been excreted on the surface. It
is certain that impure air, &c, do produce a powerful impression on the skin,
and that, in many instances, its offices are entirely suspended ; but it is equally
true, that the effect on the skin is one of sedation and depression — one affect-
ing the nerves which are there distributed — and that the cause which produces
an impression on a tissue whose connection with the nerves is so intimate and
extended, must in that way create no inconsiderable disturbance throughout
the whole nervous mass. If sedation be produced on the nerves at their ex-
tremities, the same impression will be made at their internal terminations,
and of the other nerves connected with them — those which most resemble
them in function, or which are more susceptible to the influence of any de-
pressing agent, will most readily take on the same action or condition, and
thus reproduce in the organs to which they are distributed, a state similar to
that which exists on the surface. Thus it becomes plain, how and why an
impression made on the skin can develop the tubercular cachexia in the human
economy.

The last series of morbific agents to which I will refer, are those which
connect themselves with the emotions. It is universally admitted, that the
gratification of lust, indulgence in onanism, depression of spirits, violent
grief, and, indeed, all passion whereby immediate depression or subsequent
reaction is induced, tend materially to the development of the tubercular
diathesis. Thus it has been established by the investigation of M. Lombard,
of Geneva, that twice as many die of consumption among the destitute as
among the rich and contented ; and Morton1 declares that he knows of " no
cause more certain in the development of phthisis than grief, especially when
it is long indulged f* and " that nearly every case of the disease which had
come under his observation, was occasioned by mental suffering of a protracted
duration/' Laennec tells of a community of nuns, which, in consequence of
having to submit to certain moral influences of a most terrible nature, was
so victimized by consumption, that it had to renew itself three times in ten
years. Hippocrates himself affirms, that " the abuse of youth by inordinate
indulgence in the pleasures of love, has the most unhappy influence upon the
development of consumption/' Dupay3 tells of the terrible ravages made by
phthisis among the French soldiers detained at Chatham, in consequence of

Treatise on Consumption.

2 These de 1847.

96 Warren, Influence of Pregnancy on Development of Tubercles. [July

their distress at being confined in prison, and desire to return to their native
land. Amistoy expresses himself thus : " La misere, a. coup siir, est un grande
cause de debilite, et par consequent de phthisie ; mais il-y a une autre cause
qui ruine encore plus promptement et plus profondement l'organisme ; ce sont
les passions tristes et concentrees."1

Wood says, that exhausting indulgences, grief, anxiety, disappointment,
whether of the affections or in business, are among the predisposing causes of
phthisis.

Williams enumerates among the most common causes of the constitutional
origin of consumption, " depressing passions, such as disappointed love, anxiety,
or distress from reverses of fortune, or other severe calamity, and venereal
excesses."

I have thus been particular in bringing forward the statements of these
writers, not because there can be any doubt respecting the fact to which they
testify, but as a sure means of making it conspicuous and comprehensible.
My object is to impress it fully on the minds of my readers, so that I may
the better illustrate the truth of the conclusion which is deducible from it.
Now let me ask : How do these causes operate in the production of their re-
sults ? Is it through the instrumentality of the nerves, or not ? Do not all
mental states directly influence the nervous system ? Cannot the wear and
tear of the mind be detected by the destruction it occasions to the nervous
tissue, and the presence of that debris in the excretions ? These questions
require an affirmative answer, or the reciprocal relations of mind and nerve
is an idle fancy, the connection between cause and effect a chimera, the
laws of nature uncertain in their operation, and the long established opinions
of the most learned physiologists visionary and unreliable. Here, then, we
have a certain effect associated with a particular cause, which, from its intrinsic
nature, is exclusive in its operation, and it follows that the relation between
the two is necessary and invariable. A protracted state of mental depression
produces nervous sedation and debility as a matter of course, and hence they
may be assumed as synonymous as far as they relate to the system at large.
This is the cause to which I have referred above. A tubercular diathesis
implies the existence of a certain impairment of the digestive process, which
manifests itself by a faulty transformation of the oleaginous elements into
chyle, an insufficient formation of fibrin, &c, and it is fair to consider them
(that is, the internal derangement and external manifestation) as identical
also. These constitute the effects of which I have previously spoken. A
certain abnormal state of the nervous mass produces, then, that condition of
the digestive apparatus which prevents the formation of a proper emulsion
out of the fatty matters ingested, and in this manner it becomes apparent
that the cause of consumption must originate in the nervous system. It is
evident, that an impression made on the nerves can only affect the process of
digestion, by increasing or diminishing the amount of nervous force distributed
to the organs by which it is affected. If the amount be augmented, as shown
by Bernard, the organs will secrete a greater quantity of the fluid appertain-
ing to them, and the process will be more active than under ordinary circum-
stances; and, on the other hand, when there is a deficiency in the supply,
torpor ensues, a smaller amount of fluid is poured out, and digestion is im-
paired. It is manifest in the tubercular cachexia, that, so far from there
being activity in the process, the most unmistakable impairment and derange-
ment exist, and the conclusion is inevitable, that the peculiar morbid pheno-

\ Those, 1853.

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 97

mena to which I have alluded result from an improper supply of nervous
force to the pancreas and other organs connected with the digestive apparatus.

(2.) Special Causes. — It is not important, in this connexion, to investigate
the nature and operation of those influences which tend to develop phthisis,
and for that reason I will limit myself simply to an enumeration of them.
These causes may be divided into two classes also — Mediate and Immediate.
(a) Mediate causes. These do not exercise any direct influence upon the
lungs, but affect them secondarily. Thus — the constant confinement of the
body to the same attitude ; sedentary habits; improper clothing; suppression
of habitual discharges, and all those agents which indirectly produce congestion
of the pulmonary membrane or tissues, (b) Immediate causes. By these
are meant all causes which directly affect the lungs, producing irritation, con-
gestion, or inflammation in them. To this class belong those professions in
which the lungs are constantly affected by the contact of irritating substances,
as stone-cutting, seissor-grinding, &c. ; pneumonia, bronchitis, emphysema;
and everything which directs the circulating fluid immediately upon the pul-
monary tissue. It will be seen, however, that this distinction is merely a
nominal one, and that both classes of causes require the development of a
certain amount of" irritation, congestion, or inflammation of the lungs, as
an essential condition to their successful operation.

In another part of this paper I mentioned the fact that tonics exercise a
most beneficial influence upon this disease. I propose now to consider the
nature of the action of this class of medicines, for the purpose of demonstrat-
ing still more conclusively, that the development of the tubercular diathesis
depends upon some lesion of the nervous system.

It cannot be denied that tonics act directly on the nervous mass, and that
their beneficial influence is owing to the effect which they produce on that
particular tissue. They stimulate gently, but effectually, the nervous centres,
so that an increased amount of nervous force is generated and transmitted to
the various organs, and in that manner conduce to the health and harmony
of the whole system. This explanation of the action of these remedies is
universally admitted, and it is unnecessary to inquire further into its truth.
It is well known that the mistaken opinions of Sydenham, Portal, Morton,
Kush, and others,1 respecting the essential nature of phthisis, which led to
the employment of the lancet and other antiphlogistic remedies, have given
place to sounder views on the subject, and that a more rational and successful
treatment of the affection is pursued at the present day. Without considering
it a chronic pneumonia, as taught by Broussais, or a perverted secretion, as
supposed by Andral, Carswell, Forbes, and Clark, the Profession, with a sin-
gular but most fortunate unanimity, has adopted that explanation of its phe-
nomena which attributes them to the operation of some cause that depresses
the nervous system, and in that manner prevents the proper performance of
the digestive functions. Constant exercise in the open air, together with the
use of tonic remedies, is now recommended everywhere, as the most effectual
means of relieving the peculiar morbid condition known as tubercular dia-
thesis. Now, as no remedy can be more of a tonic in its influence on the
system than exercise, and as. the medicines selected belong to that class
exclusively, it follows that the necessity which exists for this course of treat-
ment, demonstrates that a condition of debility and torpor has been induced
in the economy, causing the generation of a deficient supply of nervous force,
and its improper conduction to the various organs.

I have thus examined at length into the circumstances which attend an

1 Stokes still urges the antiphlogistic plan.

98 Warren, Influence of Pregnancy on Development of Tubercles. [July

improper digestion of the fatty elements of the food, as it appears in con-
nection with the tubercular cachexia, and have demonstrated that no emulsion is
formed, and no assimilation takes place because of some defect in the pancreatic
juice, dependent upon an improper supply of nervous force to the organ by
which it is secreted. The explanations given seem to be more reasonable
than those of Bennett, and I trust they will prove satisfactory to my readers.

M. Bernard has shown, by many interesting and conclusive experiments,
that the liver has three most important functions — Depuration, Sanguifica-
tion, and Equilibrium.

(1.) Depuration. — It has long been admitted that the liver, by secreting
bile, assists the lungs in the elimination of carbon from the economy. This
fact is substantiated by comparative anatomy, which demonstrates the anta-
gonism of the two organs, at the different ages and the several degrees in the
animal scale. Some suppose that the liver separates the bile from the blood,
so that its carbonaceous elements may be burned off in the lungs; but this
opinion has not stood the test of experience. Under ordinary circumstances,
there are more of the carbo-hydrogenous elements formed than the lungs can
burn off, as is shown by the deposition of adipose in the various tissues; and
hence the existence in the economy of another organ by which this excess
can be disposed of. If they were reabsorbed after being eliminated, the liver
would be called upon to perform an unnecessary office in secreting them ori-
ginally, and instead of being a depurative organ, it would possess features of
an entirely opposite character. One of the functions of the liver evidently is,
to eliminate from the system that surplus of carbon and hydrogen which is
not required by the tissues or the lungs.

(2.) Sanguification. — In addition to this function of depuration, which has
been recognized by all observers, Bernard contends that the liver has other
offices. He has shown by positive experiment that this organ is instrumental
in the formation both of fat and fibrin. Besides the appropriation of olea-
ginous material from the chyle, there is another source of fatty supply to the
system. Magendie established by experiments, that whatever might be the
amount of fatty material taken in the stomach, only a fixed and limited amount
was acted on by the intestines, and a still smaller quantity assimilated by the
various tissues. Boussingault fed ducks and pigeons exclusively on fat, and
found but little more oily matter in their blood, than in that of a number of
the same birds to which all food had been denied. Pusay found, in fattening
geese, that the oleaginous matter formed in their bodies was more than double
the amount that could be extracted from the corn consumed. These facts
necessarily indicate the existence of some other means whereby fat is produced
in the economy ; and hence the investigation of Bernard, by which was dis-
covered the manner of its formation. Beginning by refuting the theories by
which Liebig and Chambers had attempted to account for the results of the
above experiments, he demonstrated that the blood which enters the liver has
no fat in it, whilst that in the hepatic veins coming from it contains oleagi-
nous material in abundance, whether the aliment taken in the stomach pos-
sesses the fatty element or not; that " the blood in the arteries coming from
the lungs through the heart, contains nearly as much fatty matter as the
pulmonary arteries, and that such is the case throughout the arterial circu-
lation; while, on the contrary, in ordinary venous blood, there can scarcely
be discovered a trace of it;" and that a section of the pneumogastric nerve,
or a violent impression made on the nervous system, materially interferes with
the production of this material.

By a course of reasoning, and experiments precisely similar, he arrived at

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 99

the same result respecting the formation of fibrin. He found that " the blood
which enters the liver, contains in large quantity the digested azotised matter,
and but little fibrin, even when the animal has been fed on meat. Whereas,
the blood of the hepatic veins contains much fibrin and but little of the albu-
men: and further, that this difference is only observed during digestion."
From these facts he concluded that it is the function of the liver to produce
fibrin for the blood.

(3.) Equilibrium. — There is a constant demand on the circulating fluid
both for fat and fibrin ; and hence the necessity for the continuous develop-
ment of these materials. The liver thus becomes the instrument by which
this equilibrium is maintained in the blood and health secured to the economy.

Now, it is evident that the performance of these various functions is essen-
tial to the health- of the economy, whilst an interruption of them must produce
a succession of morbid phenomena of a definite character. If depuration be
not effected, the burden of combustion and elimination must be thrown upon
the lungs, and a disposition to disease in that organ will manifest itself. If
fat be not formed, there will be a demand made upon the tissues in which
oleaginous elements have been deposited, for carbon and hydrogen, and ema-
ciation will ensue. ; If fibrin be not properly generated, the tissues will not
be renewed, a cachectic condition of the system will be developed, a depression
of the vital powers will result, and the exudations of plasma will lose their
plastic and organic character. In a word, that condition of things will present
itself which is recognized as the tubercular diathesis.

In a previous article it was demonstrated, that an impression made upon
the nervous system by which its generating or conducting powers are inter-
rupted, operates in such a manner on the organs concerned in secretion, as to
interfere with their normal action and to restrain or alter their natural fluids.
If, then, it can be shown that the functions of an organ are interfered with,
without the interposition of a local and palpable influence, it follows, neces-
sarily, that some morbid impression has been made upon the nervous system
which has operated as the cause in the production of these particular morbid
effects. But the functions of the liver have been materially interfered1 with,
as is evinced by the symptoms which characterize the tubercular cachexia, and
hence it follows that the primary lesion in phthisis consists in the existence
of a condition of debility and inactivity in the nervous system. We have,
then,

(1.) A condition of nervous debility.

(2.) A withdrawal of the proper nervous supply to the pancreas and liver,
producing torpor in them.

(3.) An interference with the natural functions of these organs.

(4.) Emaciation, enervation, pulmonary irritability, unnatural products, and
the whole train of symptoms which distinguish the consumptive diathesis.

The most important changes effected in the economy are those to which the
blood is subjected, though they follow naturally from the explanations already
given respecting the essential nature of this particular diathesis. As a mat-
ter of course the red globules and fibrin are diminished, whilst a relative in-
crease takes place in the albumen.

(I.) Organic Impression. — When the tubercular diathesis has been deve-
loped, a morbid impression is produced upon the lungs, which renders them
particularly liable to congestion and irritation. The blood no longer abounds

1 Clark, Abernethy, Philip, Ayre, and Todd.

100 Warren, Influence of Pregnancy on Development of Tubercles. [July

in rich supplies of organizable elements ; tbe cell-germs which were once con-
veyed to the remote tissues, and deposited as the nucleus of a plastic struc-
ture, have been replaced by a degraded element, which inclines to exudation
and is susceptible of no higher development than that which characterizes the
aplastic deposit. The evil produced by the presence of such elements in the
blood demands their withdrawal, and that organ in which a proclivity to irri-
tation has been developed, and whose function is most essential to vitality and
health, becomes at once the instrument by which this elimination is attempted,
and the receptacle of morbid products. The lungs are susceptible to the action
of the morbific agent, both from causes which are original or intrinsic, and
those which are acquired — the distinguishing feature of each consisting in the
fact, that it promotes either congestion or irritation of their membrane or
tissue.

(1.) Original Causes. — The lungs are susceptible to morbific impressions
for the following reasons : because of the great amount of blood circulating in
them; they are constantly the seat of vital action and organic change; their
lining membrane is exceedingly delicate; secretions are prone to collect in
them instead of being removed.

(2.) Acquired Causes.1 — In phthisis we have — 1st, an interruption of the
function of the skin, which throws the burden of exhalation on the lungs; 2d,
a general debility, by which every tissue is weakened; 3d, excessive action in
the lungs because of the improper performance of depuration elsewhere, and
the manner in which combustion takes place in the other structures, &c. In
this diathesis, these causes combine, and render the lung so irritable and in-
flammatory, that it becomes necessarily the centre of sanguineous determination
and exudation. As the plasma thus poured out is deficient in healthy fibrin,
and as the tissues with which it is brought in contact do not possess their
normal amount of formative power, proper organization is impossible, and
hence, a low, retrograde, aplastic product is developed.

§ II. I shall devote this article to a brief consideration of the views enter-
tained at different periods respecting Phthisis, and an examination of the
nature of the tubercular deposition in the Pulmonary Parenchyma. In re-
gard to the nature of the disease, a variety of conflicting opinions have been
expressed by various writers.

Hippocrates evidently knew very little about this affection, for he considered
phthisis " an ulceration of the lungs, having for its essential character an ab-
scess which produces pus" Galen was no better informed, for he agreed With
Hippocrates in regard to the disease and its product.

Morton says, that " in consequence of some essential depravity in the blood,
there is separated from it a material of an, unhealthy and unnatural character,
which is secreted in the tissue of the lungs, and diffuses itself into the other
organs/'

Portal thinks, that "indurations which are the product of inflammatory
action, really constitute the basis of phthisis." Baumes and Bayle de-
scribe simply a pulmonary ulceration as phthisis, and confound pus with
tubercle. Langlois makes tubercle an engorgement of the lymphatic gan-
glions. Van Swieten and Fournet believe that they originate in extravasated
blood. Laennec considers tubercle an organized body having a special exist-
ence and a peculiar character. Billings regards these products as a strumous
disease of the small lymphatics of the lung, growing by the addition of lymph,

1 See Fourcault, Williams, Bedcloes, and others.

1857 ] Warren, Influence of Pregnancy on Development of Tubercles. 101

and assuming various grades of organization according to the condition of the
circulating fluid. Gulliver and Vogel agree in saying, that "it is organized
and contains cells, and that it spreads by its own inherent power of develop-
ment." Broussais teaches that inflammation of the lung is the essential cause
of the whole morbid series; whilst Hufeland and Piorry think, that though
this may be the proximate cause, there is a previous condition of debility ne-
cessary to its operation. Boerhaave says, " consumption is developed with
most facility where the air is damp and unfavourable to free perspiration;
causing the particles which should be thrown off by that operation to collect
in the system."

The most popular theories, however, are those which have been proposed
by Andral, Carswell, and Williams. Andral says: "Tubercle is nothing else
than the secretion of a matter, which seems to be produced indifferently either
in the last bronchi, in the vesicles which succeed them, or in the interlobular
cellular tissue. This matter, which seems to be primarily liquid, becomes
solidified at a period more or less remote from that at which it was secreted,
and becomes tubercle."

Carswell1 believes " tuberculous matter to be a secretion sui generis as totally
destitute of organization, as effete matter continuously separated from blood
when that fluid is in an unhealthy state, and thrown out on the surface of
mucous membranes, and producing bad consequences only in proportion as it
accumulates in organs, impedes their functions, and acts on them as foreign
matter."

Williams9 refers tubercle " to a degraded condition of the nutritive material
from which old textures are removed and new ones formed; and differing
from plasma not so much in kind, as in degree of vitality and capacity of
organization."

It is manifest, from the investigations already attempted in this paper, that
the last explanation approaches nearest the correct one, for the reason that it
is based upon proper views of the pathological condition characteristic of the
tubercular diathesis, and is susceptible of demonstration, both by d priori argu-
ments and a posteriori deductions. It is plain, that a peculiar irritability of
the lungs must occasion inflammation in them, and that, as the plasma is de-
ficient in healthy fibrin, and the tissues wanting in their normal formative
power, the materials which should have been appropriated fail to be organized
and degenerate into tuberculous matter.

Nature of Tubercle Bennett draws the following conclusions respecting

the nature of this product : —

(1.) Tubercle consists of an animal matter mixed with certain earthy salts.

(2.) The relative proportion of these varies in different specimens.

(3.) The animal matter certainly contains a large amount of albumen,
whilst fibrin and fat exist in very small quantity.

(4.) The earthy salts are principally of the insoluble phosphate and car-
bonate of lime.

(5.) Very little difference exists between the matter of tubercle and other
compounds of protein.

These conclusions, especially that which refers to the animal matter con-
tained in tubercle, follow necessarily from the explanations given of the changes
which occur in tubercular cachexia, and hence, they become most convincing
and unanswerable proofs of their logical truth and pathological accuracy.
If the normal amount and quality of fibrin were generated, the products of

1 Williams and Clymer on Respiratory Organs.

2 Principles of Medicine.

102 Warren, Influence of Pregnancy on Development of Tubercles. [July

exudation would not only contain that substance, but would present distinct
evidences of its power of organization, whether they were appropriated or not;
and, on the other hand, if it were replaced by albumen1 there would be neither
appropriation nor organization, and the matter deposited would contain that
principle (albumen) in excess. Tubercle contains but little fibrin, and does not
organize. Its principal constituent is albumen, as shown by positive analysis ;
hence, the conclusion is irresistible that the blood is deficient in the one and
rich in the other. If fibrin be not produced, then, the organ which generates
it naturally does not act properly. But that organ, the liver, will perform
its functions unless it be prevented by the interposition of some local cause, as
congestion, irritation, &c, or the withdrawal of its normal supply of nervous
force. Examinations made before and after death, conclusively demonstrate
that this local impediment does not primarily exist, and it follows, both from
this exclusive argument and from actual experiment on the pneumogastric
nerve,3 that the cause of the interruption is to be found in some altered con-
dition of the nervous system. If this alteration were upwards, that is, in the
direction of excitation, the organ would act more promptly and effectually;
whilst if it were in the opposite direction, towards depression, torpor would
result. It is evident, then, that this alteration in the system, that state which
is the primary and essential lesion in the tubercular cachexia, consists in a con-
dition of depression of absolute nervous debility, and nothing less.

Hokitansky3 divides tubercles into three kinds : simple-fibrinous, croupo-
fibrinous, and albuminous. Laennec and others describe several varieties;
but it is now generally admitted that they are all different forms or conditions
of the same substance. Robin declares that tubercular matter is invariably
yellow; but this inquiry is not material to the subject under consideration,
and consequently I shall not pursue it further.

§ III. In the first part of this paper several conditions were assumed to be
essential to disease, and it now remains to be determined whether or not
phthisis, as explained in the preceding pages, complies with all of them.

(1.) An altered condition of the system resulting from the action of some
general cause, and favourable to the operation of some particular one, was de-
clared to be the first step in the morbid process whereby disease is developed.
I have already shown that in consequence of the effect produced by the gene-
ral causes to which I have alluded, a condition of debility, of low, vital, and
organic action results, in which the circulating fluid becomes vitiated, and by
which the lungs are so impressed, as to become particularly susceptible to all
irritating and congesting influences, whilst their formative power is materially
abated.

* (2.) A particular cause acting in a special manner, was the next element
mentioned as necessary to disease. From the explanations given already, it
is evident that phthisis is not developed until some special cause presents
itself by which the pulmonary tissue is made to take in a particular inflam-
matory action, wherein exudation takes place, which, from the impoverish-
ment of the circulating fluid, and the altered condition of the tissues them-
selves, fails to organize, and deposits itself in the form of tubercle.

(3.) Effects or symptoms were then referred to as constituting the last
link in the morbid ch; in. In phthisis they are twofold — that is, those which

1 " Fibrin may be considered albumen in an advanced state of development." —

Simon.

z See Bernard's Experiment.

3 JIandbuch der Patb.ologisch.en Anatomie, 1846.

1857.] "Warren, Influence of Pregnancy on Development of Tubercles. 103

result from the action of the general cause, and others which are referable
alone to the special cause, present themselves as concomitant phenomena. By
the first, I mean those symptoms which are characteristic of the tubercular
diathesis; and by the second, I refer to the effects of tubercular deposition
upon the system at large.

These effects are so well understood as to render it unnecessary for me to
attempt any description of them in this connection. I have thus shown that
phthisis complies with the conditions essential to disease, and that in doing
so it serves to substantiate the truth of the explanation given of all morbid
processes.

In order to comprehend fully the deductions intended to be drawn from
these conclusions it is necessary to revert to that portion of this paper in which
the doctrine of antagonism was expounded and demonstrated. It was thus
shown that the only sure means of altering any particular condition of the
economy, was to induce a state dissimilar and antagonistic to that already ex-
isting. Effects or symptoms were declared to be the only means whereby
causes make themselves known; and as the particular cause depended for its
operation on the existence of a general morbid state, induced by the action
of some general cause, a continuance of the same morbid phenomena indicated
that no change had been effected in the original abnormal condition; and that
the curative process had not been commenced ; whereas a change in the pheno-
mena, proved that the original abnormal condition had been altered, and that
the succession of morbid actions was broken up. From these considerations
it is evident that phthisis must be opposed by that condition which is antago-
nistic to it, and that the induction of phenomena dissimilar to those character-
istic of this disease establishes the fact that its progress has been arrested. If
it can be shown, then, that pregnancy establishes a state in the economy which
is distinguished by effects directly opposed to those induced by phthisis, then
it follows that the particular cause has ceased to operate — that the morbid
condition by which it was favoured and permitted to affect the system has
been removed, and that an antagonistic and curative impression has been made
upon the economy. The object of the succeeding pages shall be to investigate
the nature of pregnancy, in order to demonstrate that it is essentially antago-
nistic to the progress of consumption.

Chap. IE. § I. Pregnancy. — Nothing can be more important in all its
bearings than that process by which the ovum is fecundated, the uterus im-
pregnated, and the foetus developed. Upon its proper performance and suc-
cessful issue the perpetuation of the race depends, whilst the most serious phy-
siological changes accompany and distinguish it. The organs concerned in this
important work, possess a degree of adaptation to the duties imposed upon them
as extraordinary as it is complete; a delicacy of structure unsurpassed by that of
any other tissue, and an intimacy of relation with the system at large as won-
derful in itself as it is important in its consequences. The uterus, in the female
system, is the great fountain of sensibility and sympathy. When its tissues
are intact, and its functions properly performed, the highest condition of health
is maintained in the economy; whilst the slightest deviation from the normal
standard, either in its structure or in the manner of its action, is felt through-
out the entire frame, and responded to by every organ. Hippocrates long
since enunciated a truth which has been universally received : "Morborum
omnium qui muliebres vocantur uteri in causa sint;" whilst the declaration of
Yan Helmont, "propter solum uterum est mulier, id quod est," has passed
into a physiological axiom. The actions whereby pregnancy is developed and
perfected have their seat in this organ, and hence the nature of the relation

104 Warren, Influence of Pregnancy on Development of Tubercles. [July

which they sustain to the organism. Their influence upon the economy is
most powerful and controlling, whilst the system in turn materially affects
and modifies them.

Under ordinary circumstances, each cell possesses the power of reproduc-
tion j the tissues are capable of selecting and appropriating those elements
which are essential to their nutrition; and the organs have an inherent ability
to perform their functions properly. When there has been no impairment of
the vital principle, and the body is in a state of absolute health, these processes
are performed in such a manner as to secure the most perfect equilibrium and
harmony in the economy. Physiological acts, then, require this condition of
things as an essential prerequisite to their proper peeformance, and when they
are successfully executed, evidence is thereby presented of the existence of a
condition in which the vital principle possesses its normal amount of activity,
and the system is up to the standard of health. The uterus sustains relations
of the most intimate and complicated nature with every other organ of the
body. When diseased, the whole system feels the morbid impression, and
presents infallible evidence of sympathy and suffering, whilst it in turn re-
sponds to the affections of other organs, and suspends its functions upon the
invasion of any serious malady. If the integrity of the uterine functions be
so dependent upon the healthful condition of the organism, and so indicative
of the absence of serious disease, then, a fortiori, the perfection of its highest
physiological act must require the suspension of all morbid conditions, and
serve to demonstrate conclusively that they have been suppressed. Hence,
the vast importance of this process, not only because of its effect upon society,
but for the reason that it exercises a controlling and conservative influence
upon the whole economy, whilst its successful issue demonstrates the abate-
ment of abnormal actions and the suspension of all diseased conditions.

In treating of the nature of this great physiological process, I shall limit
myself to a consideration of its effects upon the uterus itself and the system
at large. One of the first evidences of pregnancy is the suspension of the
menstrual flow, which results, not on account of any disease, general or special,
but because the fluid is required for other purposes in the system. The symp-
toms which ordinarily attend the retention of this fluid, do not appear, for the
reason that nature in her effort to perfect a high physiological act, gives to the
system a certain tolerance or power of resistance that it does not ordinarily
possess. The structure of the uterus is materially changed; its fibres are se-
parated; numerous interspaces are left between them, and a positive addition
is made to its substance. The cavity of the womb is materially increased in
size, and filled up, not only with the foetus itself, but with an entirely new
membrane of fibrinous origin and character, rapid in its development, and im-
portant in its purposes. The vessels increase in number and capacity, which
augmentation of vascular machinery implies, of course, an increase in the
amount of circulating fluid in the womb. The nerves become hypertrophied
from an absolute increase of substance, so that the sensibility of the organ is
augmented, and its relations with the organism rendered more complete. In
a word, it not only becomes the centre of nervous and vascular determination,
but by reason of the increased vital action in it and the system at large, it
acquires a principle of growth, and so increases in capacity as to accommodate
itself to the importan j development within its cavity.

It produces in the system a condition of increased action, approaching eveu
to plethora. This is evinced by the addition made to the vascular machinery ;
the augmentation of circulating fluid; the buffy coat of the blood; the un-
usual frequency of the pulse; the acquired tolerance of the lancet; increased
susceptibility to the action of stimulants; difficulty of employing tonics to

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 105

advantage, and the proteinaceous products which are developed within the
womb. The testimony of able writers may be adduced in favour of it also.
u In the earlier stages of pregnancy especially, general and local plethora fre-
quently presents itself." (Cazeaux.) "In pregnant women a physiological
condition appears in which there is a positive augmentation of the mass of
blood relatively to the capacity of the vessels." (Becquerel and Rodier.)
" There is a tendency to the production of more blood than formerly."
(Bums.)

"The general state is said to be one of plethora." (Churchill.) "The state
of pregnancy is one of increased vascular action, not only in the great organ
primarily affected, but generally throughout the system, by which a disposi-
tion to plethora is created." (Montgomery.)

Authorities might be multiplied indefinitely, for nearly every writer on the
subject expresses the same opinion respecting the state of the system at this
important period. Now, whatever may be the views of these authors, re-
specting the exact definition of the term plethora, there can be no doubt of
the fact which they intend to assert, that a condition of excitement, of ultra
health, of increased vital activity, attends and characterizes pregnancy in its
development and progress.

This disposition to the establishment of inflammatory action, fevers, acute
affections, &c, is so imminent as to require the production of a certain
method of relief to the economy, whereby its normal condition may be
secured and retained. A kind of safety valve is established through which
this morbid proclivity may work itself off, without producing disease to the
system. Thus, Denman has remarked, "It is a popular observation, that
those women are less subject to abortion and ultimately fare better, who
have such symptoms as sometimes attend pregnancy, than those who are
exempt from them." Nausea, vomiting, disgust for food, &c, serve to re-
strain the disposition to disease characteristic of this condition, and to keep
up the natural balance in the system, by lessening the quality of the circu-
lating fluid, diverting nervous excitement, preventing plethora, and develop-
ing that state in the economy which is essential to the perfection of nature's
most important work.1

Nothing is perhaps more indicative of the existence of this state of reple-
tion, than the necessity which presents itself for the employment of the
lancet, and the unanimity with which its advantages have been recognized by
the profession. It is true that Hippocrates declares, " mulier in utero ges-
tans, incisa vena abortit, idque magis si est foetus auctor;" but his opinion
is based upon the supposition that the suppression of the menses indicates a
necessity for a superabundance of blood, and that its abstraction is in opposi-
tion to a law of nature. He, however, purged pregnant women excessively,
as a means of preventing the appearance of plethora; and thus assisted in the
establishment of a principle in direct opposition to that which he has enun-
ciated in the 35th aphorism of his 5th Book.2 Fernel was the first who dis-
sented from the views of the sage of Cos, and bled pregnant women. He
expresses himself in the following manner :3 " II ne sera pas hors d'apropos
d' examiner si la grossesse doit etre une contre indicacion a la saignee. Des
considerations specieuses appuyees sur l'avis d'Hippocrate, nous engageraient
a la reserve lorsque il s'agit des femmes enceintes, meme atteintes d'une
maladie grave dans la vue du foetus, qui pourrait en souffrir. Mais il n'est
nullement constant de voir avorter une femme enceinte a laquelle on ouvre la
veine, pas plus que de voir mourir necessairement une femme enceinte

1 Churchill, Dewees, et al.

2 1558.

3 Ferneli Opera, Hv. 2d.

106 Warren, In fluence of Pregnancy on Development of Tubercles. [July

atteiDte d'une grave maladie."1 Guillemeau, who lived towards the end of
the 16th century, sustains Fernel and gives both rules and reasons for the
use of the lancet in pregnancy. Mauriceau says, that in his time (17th
century) nearly all pregnant women insisted on being bled at half term, and
the seventh month. He makes a just criticism on the teachings of Hippo-
crates in the following words : " Cet aphorisme ne nous doit pas defend re
l'usage de la saignee quand lecas le requiert; mais il nous fait settlement eou-
naitre, qu'il s'en faut servir avec une grande prudence, d'autant qu'il y a telle
femme qui a besoin d'etre saignee trois on quatre fois, et quelquefois davan-
tage pendant sa grossesse, et a une autre deux seulement suffisent.'1 In the
first half of the 18th century, Dionis, Puzos, and Lamotte speak of preventive
bleedings, and recommend the employment of the lancet. Dionis thinks
that a woman should be bled at four months and a half, at the seventh
month, and again at the eighth month, if plethoric symptoms continue to
present themselves. He gave as reasons for the employment of the lancet,
the following facts : a larger amount of blood is produced than under ordi-
nary circumstances ; an unusual supply is retained iu consequence of the
suspension of the menses; those women who menstruate during pregnancy
are healthier than those who do not ; and plethoric symptoms are relieved by
this remedy with facility and certainty. Puzos advocates bloodlettiug also,
but insists that the number of bleedings requisite for the proper control of
morbid symptoms, cannot be fixed upon in advance. Levret bled in the
cases marked by plethoric tendencies, and recommended the lancet as an
invaluable agent in the accidents incident to that particular condition. The
ablest writers of the 19th century have approved and tested those principles
thoroughly. Thus, Gardien, Yelpeau, Dubois, Piorry, Andral, Cazeaux,
Becquard, Rodier, Chailly, and many others, have arrayed themselves among
the advocates of the lancet, and borne irrefragable testimony in support of its
utility, propriety, and necessity, in the arrest of that plethoric condition
developed by pregnancy in the female system. Denman affirms that "vene-
section is found useful even in those constitutions which do not ordinarily
bear it well." Dr. Burns says, "it is necessary frequently to lessen plethora
and local irritation by bloodletting/' Dr. Dewees draws the following con-
clusions, after a thorough examination of the whole subject : '"Women bear
the loss of blood better when pregnant than at any other time. The acute
diseases of pregnant women require a more extensive use of the lancet than
under ordinary circumstances/' But it is useless to multiply authorities, as
it might be done indefinitely, for the opinions thus expressed are held by the
ablest writers of all countries at the present day. From a consideration of
these authorities and the facts to which they have testified, the following
conclusions are inevitable : —

(1.) The utility of the lancet in pregnancy has been demonstrated.

(2.) This utility depends upon the fact that a disposition to plethora exists
in connection with that condition.

It must be explained, however, in this connection, that the term plethora
is not employed in the limited sense of a mere excess of red globules, as
defined by Andral, but as meaning either an augmentation of the whole
volume of the circulating fluid, or the increase of some one of its vitalizing
elements. An examination of the blood will not only show that there has
been more formed than usual, but that fibriu, its most essential principle, is
largely increased. According to Becquerel and Rodier, the average propor-
tion of red globules in man is 141 to 1000 parts of blood; and in woman

1 See Guillemeau, 1608, p. 30, et suiv.

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 107

127. This average decreases progressively during pregnancy, not because
the blood becomes impoverished, but in consequence of the great demand for
fibrin, and the extraordinary production of that material.1 During the first
months, it remains at from 116 to 126; in the sixth and seventh months it
averages between 100 and 120; whilst towards the close of the process it
varies from 90 to 100. Albumen is about 70 in the state of health; in
pregnancy it descends below 60. Fibrin is never found below the ordinary
standard, but is always above it. Its average toward the end of pregnancy
varies between 3.69 and 4.69, lower than in any other pathological state.3

Respiration is slightly increased, in the first instance, but diminishes sub-
sequently as the uterus enlarges.3 Thus, the process of oxidation does not
take place so rapidly in that organ, and the principal burden of depuration is
thrown upon the liver. The nervous system is in a state of excitement, as is
shown not only by increased vital action, but by the wakefulness, watchful-
ness, &c, which distinguish the pregnant state.

The secreting functions participate in the general excitement, as must result
from the altered condition of the nervous mass, and as is established by the
action of the salivary glands, the state of the skin, &c, at this critical period
of feminine existence.

Thus, from the character of the process which is accomplished during preg-
nancy, it is evident that the absence or subsidence of all organic disease is
demanded by nature, for the perfection of her most important work; whilst
an examination of the changes of the uterus itself, and the organism at large,
clearly demonstrates the establishment of a condition of increased nervous
energy, of extraordinary vital action, and of ultra health.

§ 2. — Having considered the nature of phthisis, together with its effect upon
the economy, and discussed the changes which accompany and distinguish
pregnancy, I shall now attempt to contrast the two, for the purpose of showing
the antagonism between them.

(1.) Phthisis has two stages, the first marked by those symptoms which
distinguish the tubercular diathesis; the second characterized by the depo-
sition of tuberculous matter in the lungs. Both are essentially morbid, de-
pending upon positive nervous debility, marked by low vital action, and attended
with distinct organic changes, of a low asthenic nature, throughout the entire
system.

Pregnancy implies the existence of a physiological process in the economy,
having for its prerequisite a certain amount of health, demanding the arrest
of organic lesions as an essential condition to its progress and perfection, and
producing a state of repletion, in which the vital principle attains its full
maximum of development, and the system is predisposed to the highest grades
of action.

(2.) Phthisis is distinguished by the presence of feeble and flabby muscles*
loss of strength, emaciation of person, and anemic appearance.

Pregnancy is marked by the extraordinary enlargement of the uterus, which
is composed chiefly of muscular tissue, increase of strength, rotundity of per-
son, and plethoric appearance.

(3.) Phthisis is preceded and accompanied by a positive impairment of the
digestive process ; a condition in which the nutritious elements of food are
improperly prepared for the use of the economy; a state which precludes
assimilation, both because of a defect in the pabulum supplied, and a diminu-
tion of the formative power of the tissues. Pregnancy is frequently attended

1 Simon, Regnault.

2 Andral and Gavarrct.

3 Rokitansky.

4 Aretee.

108 Warren, Influence of Pregnancy on Development of Tuhercles. [July

with an interruption of the process of digestion, resulting, not from any in-
abilty of the parts concerned to perform their natural functions in its accom-
plishment— not because nutritive elements are deficient or defective — not for
the reason that the tissues cannot appropriate the organizable elements upon
which they live, but in consequence of some disturbance of nervous energy,
or in obedience to that instinctive sympathy which teaches particular organs
to respond to the necessities of the organism.

(4.) Phthisis has among its essential elements an alteration in the com-
ponents of the circulating fluid. Albumen is defective and superabundant;
red globules are not produced in their normal quantity, and fibrin loses its
powers of organization, and is materially diminished in quantity. As a con-
sequence of these changes, extravasations occur readily, neither organization
nor appropriation takes place, and depositions are made throughout the system,
amorphous in their character, albuminous in composition, and distinctive in
their effects upon the economy.

Pregnancy also produces alterations in the blood, but they differ materially
from the above. Albumen remains fixed ; red globules diminish in quantity
in consequence of the great demand for fibrin; and fibrin increases up to the
highest possible ratio. The result of this change is manifested in the pro-
ducts of the uterus; for there is not only developed within its cavity a foetus,
consisting principally of proteinaceous elements, but membranes, bloodvessels,
and nerves, which are essentially fibrinous in their origin and constituents;
all of which are the direct consequences of a high physiological act, and sub-
servient to the most important purposes known to the economy.

(5.) In phthisis the great burden of combustion and depuration falls on the
lungs ; the balance maintained between them and the liver is destroyed, and
the hepatic functions materially interfered with. The pancreas, salivary appa-
ratus, skin, and secerning functions generally, are rendered torpid or irregular,
whilst the fluids peculiar to the various organs are altered in quantity and
quality.

In pregnancy the balance is disturbed, but the burden falls on the liver.1
The cavity of the thorax diminishes in capacity as the foetus is developed,
so that the lungs have less work to perform, which of course imposes the
labour of depuration on those organs that have a corresponding function.
The skin, also, for this reason, excretes with uuusual rapidity, and lends a
powerful assistance towards maintaining that equilibrium which is essential to
health. The pancreas indicates no debility or derangement, but secrete pro-
perly that fluid whereby oleaginous elements are prepared for assimilation.
The salivary organs are particularly active, as has been remarked by all
writers on this subject. Thus, it becomes evident that the state of pregnancy
is characterized, not by torpor of the organs and deficiency of the fluids, but
by a state of great functional activity throughout the whole system.

(6.) Iu phthisis, a state of absolute depression or debility manifests itself
in the entire nervous mass, so that the normal amount of nervous influence
is neither generated in the centres nor transmitted to the organs.

In preguaucy there is a condition of exaltation, of excitement, of unusual
action, developed in the nervous system, as is shown by the restlessness, irri-
tability, reciprocal sympathy, and activity of function which attend its progress.
Nervous tissue even becomes hypertrophied from excessive health, for the
nerves of the uterus are not only found more sensitive, but positively en-
larged during the continuance of the state of gestation.

(7.) In phthisis, tonics and stimulants, both local and general, are par-

1 Kokitan?ky, Montgomery, Burns, and Chailly.

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 109

ticularly indicated, whilst the employment of depleting measures is not only
uncalled for, but positively dangerous to the patient.

In pregnancy, tonics and stimulants are contra- indicated, for they serve but
to increase the tendency to plethora therein developed. Antiphlogistic mea-
sures, on the contrary, are rendered necessary by this state of general reple-
tion, and play a most important part in the subjugation of all those morbid
affections to which women are liable during the progress of fetal develop-
ment. In a word, an examination of phthisis and pregnancy clearly demon-
strates that they are essentially different and antagonistic, both as regards their
intrinsic character, the manner of their development, and the nature of the
results which they produce in the economy. If, then, the doctrines of Hah-
nemann be true, the coexistence of these two opposite conditions is possible,
and the progress of phthisis will not be restrained by the development of
pregnancy. But, on the other hand, if the principle of "antagonism" already
illustrated constitute, in fact, the great basis of therapeutical action, the ex-
istence of pregnancy must operate as a restraint upon the continuance of the
tubercular diathesis.

It is hardly necessary to assert, in this connection, that phthisis does ma-
terially interfere with those processes whereby pregnancy is developed, for it
is well known that morbid conditions cannot favour the consummation of a
purely physiological act, and that a suppression of the menses is one of the
earliest and most constant symptoms of the tubercular cachexia. Of course,
it is far easier for a woman to become pregnant, when thus affected, than for
phthisis to originate and progress during the continuance of the state of ges-
tation, for the obvious reason that health is the normal state to which there is
always a natural proclivity; and that Providence invariably manifests wonder-
ful wisdom and foresight in dealing with final causes. Here, then, are two
states sustaining certain reciprocal relations, which render them mutually
dependent upon each other. One, by reason of the characters upon which
these relations are based, serves as a check upon the other. What, then, must
be the nature of the influence exerted in return ? It must evidently be, one
of control, of opposition, of restraint. The second must affect the first, just
as the first affects the second, and it is proper to conclude that pregnancy
retards the development of tubercles in the lungs.

Phthisis makes itself known by a set of phenomena of a particular character.
Pregnancy is distinguished by phenomena entirely dissimilar and antagonistic.
Their coexistence implies the continuance of two opposite conditions in the
economy, and involves nature in the contradiction of perfecting antagonistic
processes,1 each affecting the system in all its parts and powers, at the same
time and under identical circumstances. The natural antagonism between
health and disease — between a state purely physiological and one essentially
pathological, is sufficient in itself to account for the restraining influences
which are reciprocally exerted by those two conditions ; and thus for a double
reason the antagonism between phthisis and pregnancy is rendered clear and
palpable.

Chap. III. § I. In speaking of the special causes whereby the deposition
of tubercles is effected, I mentioned that their potency depends upon a certain
capability of producing irritation or congestion in the tissue of the lungs. So
manifest is the fact, that the appearance of tubercles in the lungs is preceded
by some irritation of their structure, that many accurate observers have main-

1 See St. Hilaire, Meckel, Rudolphi, Serres and Vernois.

No. LXVIL— July 1857. 8

110 Warren, Influence of Pregnancy on Development of Tubercles.

tained that phthisis originates exclusively in such a condition. Laennec has
exploded this idea in a masterly manner, whilst Louis, Andral, and Grisolle
have sustained his position by an array of facts and argument perfectly satis-
factory and overwhelming. That irritation, congestion, &c, do play an im-
portant part in the development of phthisis, can be easily established, both
by a reference to authorities, and an examination of the phenomena connected
with that disease.

Wood declares: "Anything which is capable of irritating or inflaming the
lungs; of producing an unusual influx of blood; or an unusual secretory effort,
acts as an exciting cause to the deposition of tubercles in those predisposed to
them."

Laennec says: "Although inflammation cannot by itself produce tubercles,
it may hasten their appearance, in the same way as a soil well tilled after a
long fallow, or left fallow after several years' culture, will cause many seeds
to germinate which had lain within it in a state of inactivity for several
years."

Cruveilhier gives the following experiment: "I injected through an open-
ing made in the trachea of a dog, two ounces of mercury, the greater part of
which was rejected by coughing. The dog, however, did become apparently
phthisical, and did emaciate. At the end of two months the lungs were cram-
med with tubercles, both isolated and agglomerated."

Jackson affirms, " that the most usual exciting causes of pulmonary tuber-
cles are, neglected catarrhs, and pneumonias of a feeble grade."

Bayle even declares, " that pleurisy, pneumonia, exanthematous diseases,
&c, are sometimes the cause of phthisis, but for the most part, they only
hasten its advent."

Morten says, "Et equidem non dubito quin in herpes morbi primordiis ca-
tarrhi, tussesque communis frequenter in phthisim pulmonarem degenerare so-
leant."

Hufeland believes that, " more than half of consumptions are the results of
catarrhs."

Yan Swieten affirms that, " pulmonary congestion is the principal cause of
the development of phthisis."

Baron and Fournet have maintained the same opinion, whilst Andral ad- -
mits that "haemoptysis is in many instances the first step towards tubercular
deposition, as well as the sure evidence of the local implication."

Stokes and Clark affirm, " that some congestion of the lungs always pre-
cedes the development of tubercles."

It is well known that those influences which interfere with the functions of
the skin, and thus give a centripetal direction to the current of the blood,
operate powerfully in developing the disease. A phthisical predisposition is
also particularly characteristic of puberty, for the reason, that there is a con-
centration of nervous and vascular energy upon the lungs at that period.

The invasion of consumption is also especially favoured by those occupations
in which pulmonary irritation is constantly developed. Thus, stone-cutters,
scissor-grinders, &c, are particularly liable to phthisis.1

Lieutaud and Portal furnish instances in which phthisis resulted from the
irritation occasioned by continued fever.

Amestoy gives the case of a man who foolishly attempted to swallow a nail,
which unluckily fell first into the trachea, and then lodged in one of the
bronchi. This produced an irritation of the parts which resulted in death.

1 See Reports of Lombard, Dumeril, and Benoiston de Chateau-neuf. Archives
Generates, 1830.

1857.] Warren, Influence of Pregnancy on Development of Tubercles. Ill

A post-mortem examination revealed the fact; that the lungs had been filled
with tubercles.

Louis tells of a young butcher who received a violent blow on the chest,
and died of consumption in a very short time. From a consideration of these
facts it is evident, that in addition to the general predisposition to phthisis, a
certain amount of local irritation or congestion is necessary to the completion
of the morbid series which constitutes the disease.

Whatever, then, operates in such a manner as to prevent or relieve that
irritation, and to render the lungs less susceptible to the causes which pro-
duce it, must exercise a most healthful influence upon those predisposed to
phthisis, aud resist the onward march of the disease, even when its particular
diathesis has been established.

§ II. I shall endeavour to prove that pregnancy necessarily opposes this
sanguineous determination to the lungs, and resists the establishment of that
irritation upon which the development of tubercles depends.

(1.) The great principle of derivation and revulsion is universally appre-
ciated by medical men, and constantly invoked in the treatment of disease.
Derivation, in a therapeutical point of view, signifies that action by which the
circulating current and nervous energy are drawn towards a particular point,
as a means of diverting them from a part in which they are producing mor-
bid accidents. According to Nysten, it is "an artificial excitation designed
to break up a tendency which manifests itself in the fluids and forces to con-
centrate themselves wherever a centre of irritation exists."1

In the human system there is only a certain capacity of nervous action and
a definite amount of blood.3 Whenever there is a nervous or sanguineous
concentration upon one point, there must necessarily be a deficiency elsewhere,
and hence, the philosophy and importance of the principle of derivation in the
treatment of disease.

The value of revulsion in the arrest of phthisis, can be made evident by a
reference to a few acknowledged facts.

The use of blisters, setons, issues, &c, has been resorted to from the earliest
times, and has been found of extreme importance in the management of con-
sumption. Exercise, by giving a centrifugal direction to the circulating cur-
rent, and by stimulating the skin, &c, to proper action, frequently produces
a most happy result upon the progress of that disease. Intermittent fever3
exercises a controlling influence upon phthisis. Fistula in ano connects itself
in a special manner with phthisis, and frequently retards its march, and pre-
vents the deposition of tubercles.

Emetics have been employed in the treatment of consumption from a very
early period. Many able writers maintain that the most effectual method of.
relieving the morbid state upon which the development of tubercles depends,
is to be found in the free use of emetics. Morton particularly recommends them,
and he is sustained by Robinson, Reid, Dumas, Holland, and Carswell, all
able writers and eminent pathologists. Giovanni di Vittis has given this
class of remedies a most thorough trial, and is convinced of their great utility,
especially in the early stages of phthisis. Piorry, Bouillaud, Trousseau, Yalleix,
Louis, Andral, Rogie, Lisfranc, and many others, have tested the merits of

1 " Fluentium humorem revulsio me dela est derivatio autem eorum qua jam obsi-
derant membrum." — Galen.

2 Holland's notes. Tweedie's Practical Medicine.

3 See Memoire de M. Carriere, Bulletin de l'Academie de Medecine, 1844-5. Me-
moire par M. Lefevre, Bulletin de l'Academie, p. 968, vol. x. &c.

112 Warren, Influence of Pregnancy on Development of Tubercles. [July

this plan of treatment, and testified to its efficacy in preventing the deposi-
tion of tubercles, and arresting the march of that cachexia which precedes and
produces their development in the pulmonary tissue.

These facts clearly establish that consumption may be arrested before it is
fully developed or perfected by the deposition of tubercles; and it follows as
a necessary deduction, that when it can be established that a particular pro-
cess diverts the fluids and forces of the system towards another organ, it is fair
to attribute to that process certain curative powers and preventive influences
in connection with the progress of the tubercular cachexia.

(2.) As soon as impregnation is effected, the uterus and its appendages
become the seat of most important physiological actions and organic changes.
Under the influence of the process thus established, these parts are made
centres of nervous and sanguineous determination, to an extent that can only
be comprehended by a consideration of the wonderful results which are there
accomplished. The development of the foetus; the elaboration of organized
membranes; the increase in the vascular apparatus of the organ; the formation
and hypertrophy of the nervous filaments distributed to its tissues ; and the
perfection, in fact, of nature's highest and most complicated physiological
work, demonstrates the necessity for the presence of a full tide of blood and
nervous energy in the parts concerned in this important process, and proves
that such a concentration has been effected. As a necessary consequence the
whole system feels the effect of this derivation; and the lungs, in common with
all other organs, are relieved both from the predisposition to irritation and the
congestion which has been effected in them. Thus it becomes evident that
the arrest of phthisis in those predisposed to it — that is, before the disease
has been confirmed by the development of pulmonary irritation, &c, and the
deposition of tubercular matter — is in direct conformity with an established
law of nature, and that a denial of the fact involves the plainest principles of
therapeutics in an interminable labyrinth of contradictions.

§ III. — But pregnancy is not only opposed per se to the continuance of the
tubercular diathesis, as has been shown above; it operates also by means of
its secondary effects — if such an expression may be employed — in the arrest
and removal of this particular cachexy.1 Thus by diminishing the cavity of
the chest, it exposes a smaller quantity of pulmonary membrane to the influ-
ence of external causes, and renders the lungs less liable to disease of an in-
flammable character ; whilst by the pressure of the gravid uterus against the
liver, stomach, pancreas, &c, it stimulates these organs to increased action,
and gives additional relief to the one already suffering.

Again — some of the means whereby nature relieves herself from morbid
predisposition,3 serve in a most effectual manner to remove pulmonary irrita-
tion, and even to produce the discharge of abnormal products after they have
accumulated in the lungs.3 It is well known that one of the most frequent
symptoms which presents itself in connection with pregnancy, is excessive
nausea and vomiting. Now, as I have shown before, emetics are of great
benefit in the tubercular cachexia, for the reason " that they prevent the deve-
lopment of pulmonary irritation,4 and remove both congestion and unnatural
products from the air-passages and the subjacent vesicles." It is manifest
that the vomiting which connects itself with pregnancy, must operate in the
same manner, and thus another excellent reason is furnished for the arrest of
tubercular deposition in those predisposed to phthisis, by the development of

1 Kokitansky. Manual of Morbid Anatomy.
3 Carswell.

2 Denman.

4 Holland's Notes.

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 113

that particular symptom. It is possible also, that hsemorrhoids, which are
frequently produced by pregnancy, may serve as a centre of irritation and a
source of relief, in the same manner as fistula in ano usually does, and that
in this way some retardation of the progress of phthisis may be effected.

Holland, in his Medical Notes, affirms, that nothing exercises a more potent
influence upon the development or prevention of disease than the concentra-
tion of the attention upon any particular organ. This must be admitted by
every careful observer of morbid actions, and is received as a truism by
the profession. What can give more fixedness and concentration of attention
than the expectation of being impregnated, the assurance that pregnancy has
been established, and the certainty of becoming a mother? With what
constant watchfulness must that woman regard her womb, who perceives that
her menses have been arrested, that her abdomen is enlarging, and that a
child is developing itself within her bosom ? And if it be possible for dis-
ease to be removed from an organ, and for the nervous influence and sangui-
neous current to be directed upon another by any mental effort, under what
circumstances could it be so well accomplished as when the uterus is engaged
in the act of reproduction, and employed with all the changes, alterations, and
labours incident to that important process? Here, then, is another reason for
attributing to pregnancy the power of arresting the progress of tubercular
deposition.

The object of pregnancy is to reproduce the species and perpetuate the.
race. Like all other physiological acts, it requires certain conditions for its
perfection, which nature labours to supply with a generous and intelligent
hand. Health is essential to the proper performance of all vital actions,
and the amount of health demanded is always in direct proportion to the im-
portance of the physiological process. Pregnancy implies the existence and
progress of the most important process known to the economy. Its success-
ful accomplishment requires, consequently, the maximum development of vital
power, and the nearest approach to the normal standard of which the organ-
ism is capable ; and hence, its proper performance is an evidence of the abate-
ment of all serious morbid action, and the establishment of a condition essen-
tially antagonistic to the invasion and progress of disease. This statement is
verified by the following facts :—

(1.) Most women increase both in size and strength duriag the period of
gestation.

(2.) Women who bear children habitually enjoy better health than those
who do not.

(3.) Pregnant women are less susceptible to the influence of contagious
diseases, epidemics, &c, than others who are in a normal condition, as has
been affirmed by Bayle, Andral, Montgomery, Ashwell, Sydenham, and many
others.

Thus it is evident that nature attempts to throw safeguards around this im-
portant process by inducing that condition most essential to its success, and by
arresting every action calculated either to interfere with its progress or to pre-
vent its consummation. From these considerations it is plain, that pregnancy
must tend to prevent the progress of consumption with those in whom the
tubercular diathesis has been established.

Chap. IV. § I. As I have thus attempted to establish by facts and argu-
ments that pregnancy arrests the development of tubercles, I shall now en-
deavour to sustain that position by a reference to authorities.

" Des qu une femme est grosse, les probabilities de sa vie augment." — Gardien.

114 Warren, Influence of Pregnancy on Development of Tubercles.

" Where women who have been labouring under certain forms of disease
happen to conceive, the morbid affection previously existing is oftentimes
checked or even altogether suspended for a time, as has been frequently ob-
served of persons affected with phthisis-" — Montgomery.

"In a great majority of cases the symptoms of phthisis are suspended, or at
least remain stationary during pregnancy." — Andral.

" It is a remarkable circumstance that pulmonary consumption is very gene-
rally suspended in its progress by pregnancy." — Eberle.

"During the progress of pregnancy consumption seems to be suspended." —
Heberden.

" Des deux femmes phthisique au meme degre celle qui devient enceinte,
arrive surement au terme de la gestatione ; tandisque Fautre p6rira avant le
temps." — Rozier de la Chassagne.

" Phthisis pulmonalis frequently becomes modified during pregnancy, and is
succeeded apparently by perfect health." — Chailly.

" A very salutary change is effected in the whole system, so that persons
enjoy better health during pregnancy than at any other time." — Burns.

"The effect of disease seems also, in many cases, to be suspended during
pregnancy. I do not recollect a single instance of any consumptive woman
being unequal to her delivery, or having her fate hastened by it." — Penman.

"In females affected with pulmonary phthisis which has not reached the
hectic stage, pregnancy goes on well to the full term. The progress of phthisis
is often modified, and sometimes really arrested." — Jacquemier.

" You can understand, too, why this morbid nutritive activity, this disposi-
tion to deposit albuminous matter, should be shown in woman after the com-
pletion of utero-gestation, and in persons on the speedy healing of large sup-
purating wounds ; circumstances which, as they continue, are known often to
suspend the progress of consumptive disease." — Williams.

" Pregnancy cures hsemoptysis and hemorrhages distant from the uterus ;
chronic diseases are rendered slow in their progress, and some are cured ;
whilst a temporary benefit is experienced in phthisis." — Nauche.

" I cannot conclude better, than by a quotation illustrative of the effects of
pregnancy upon existing diseases, with which, I may add, my own experience
perfectly agrees. 'We have sufficient evidence to justify the belief, that preg-
nancy acts in a great degree as a protective against the reception of disease,
and apparently on the common principle, that during the continuance of any
one active operation in the system, it is thereby rendered less liable to be in-
vaded or acted on by another; thus it has been observed, that during epidemics
of different kinds, a much smaller proportion of pregnant women have been
attacked than others ; and when women who have been labouring under certain
forms of disease happen to conceive, the morbid affection previously existing is
either greatly checked, mitigated, or even altogether suspended/" — Churchill.

" Nature assumes her rights, and combats every disease while this important
process (pregnancy) is going on." — Parr.

"The fact that pregnancy not only checks the advance of existing tubercu-
losis, but also excludes its development, may be thus explained. As the abdo-
men enlarges, the thoracic cavity becomes encroached upon, and, the parenchyma
of the lungs being exposed to pressure, a condition of venosity results. This
is doubtless the reason why the foetus is scarcely ever, and the placenta very
rarely, tuberculous." — Rokitansky.

" They (consumptions) are often checked by the return of mild weather, but
perhaps even in a still more remarkable manner by pregnancy." — Gregory.

"That pregnancy has almost an invariable tendency to suspend phthisis, is
notorious. This I have known very strikingly illustrated in several cases, in
which every symptom of pectoral affection ceased during the period of gesta-
tion."— Chapman.

"Nature, attentive to her work, seems to forget everything to carry it to
perfection. The progress of fatal diseases is retarded, and pregnant women
labouring under phthisis, who, in the usual course of that complaint, would
soon perish, go through the regular period of utero-gestation." — Richerand.

" The symptoms of consumption are generally arrested, or at least greatly
mitigated, during pregnancy." — Morton.

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 115

" Tubercular disease is rendered latent, or at least masked, by a peculiar
condition of the system, or by the presence of other diseases. Pregnancy ap-
pears to retard, if not to suspend, its progress." — Clark.

"The arrest of phthisis is owing to that powerful excitement which the uterus
receives at this critical and important period, by which the irritative pulmonary
actions are subdued, and the impetus of vascular action directed into another
course. " — Reid.

This opinion numbers also amongst its supporters, Baumer, J. Frank, Bor-
deau, Portal, Duges, Sydenham, Grood, and many others of equal merit and
respectability ; and, in fact, has been almost universally accepted by medical
men, from the days of Hippocrates down to the present time.

§ II. M. Dubreuilh1 presented a communication to the French Academy in
1852, which utterly rejects the doctrine of antagonism between pregnancy
and phthisis, and attempts to establish that the progress of tubercular de-
velopment is really hastened by that particular condition. M. Grisolle,3 who
was appointed to report on the subject, fully sustains these conclusions, and
adduces additional arguments in support of them. Neither of them, however,
has examined the physiological questions involved in the inquiry, whilst both
base their objections to the established doctrine on the subject upon the ob-
servation of a comparatively small number of cases of well-developed phthisis
which have been brought within the pale of their experience. It is true that
they appeal to Louis,3 and invoke his experience and teachings in support of
their positions ; and, by a species of special pleading, succeed in making a
very good case for themselves. They can, however, be easily met and an-
swered, as I shall demonstrate in a few words.

1. Even if their conclusions are correct, nothing is established in opposition
to the views presented in this paper. My object has been to show that preg-
nancy prevents the development of tubercles in those predisposed to phthisis,
whilst they have laboured to prove that it does not arrest phthisis itself,
when actually established. It is certainly true that I have adduced facts, argu-
ments, and authorities in support of the power of pregnancy to retard or prevent
the progress of phthisis proper, but it has been done with especial reference
to the establishment of an antagonism between that condition and the actual
deposition of tuberculous matter, when only the tubercular cachexia exists. I
have intended to show that if pregnancy mitigates, conceals, and actually arrests
consumption when fairly developed, then, a fortiori, it must retard the depo-
sition of tubercles in those predisposed to phthisis. This is the point at issue;
and as the deductions of these gentlemen do not affect it in the slightest
particular, the conclusion is inevitable that they have established nothing in
opposition to the position assumed in this paper. I have shown that the spark
may be extinguished by certain means; they attempt to prove that these means
do not arrest the flame; so that the question which I have endeavoured to solve
is not in the least degree decided by their investigations.

2. They have not established their position. The thirty-five instances to
which they have referred, in support of their views, prove nothing when com-
pared with the thousands of cases upon which the opinions of so many writers
have been based. The authorities which maintain the existence of this "an-
tagonism" are far more numerous than the cases collected and reported by these
learned Frenchmen; and thus it becomes evident that they have done nothing
towards the overthrow of this long-established and most logical hypothesis.

1 Memoire par Charles Dubreuilh, Bui. Acacleinie de Medecine.

2 Bui. de l'Academie de Medecine, torn. xvii. p. 14.

3 Louis gives no positive opinion on the subject, and says he has not formed one.

116 Warren, Influence of Pregnancy on Development of Tubercles. [July

When they have proved that pregnancy and phthisis develop conditions which
are identical in their nature and similar in their results upon the system at
large; when they have reconciled their necessary contradictions and peculiar
antagonism, and established that an act purely vital and a process essentially
morbid require like conditions for their perfection, the same laws for their
government, and reciprocal support for their very existence, then will they
have done something towards the overthrow of principles which the common
experience of professional men proclaims to be true, and the establishment of
more enlightened and logical doctrines of medical philosophy. To those ac-
quainted with French hospitals, it will hardly be necessary to say that thirty-
five cases selected from their wards, for the purpose of sustaining a foregone
conclusion, do not furnish a sufficient basis for the foundation of opinions
which are to establish a new principle in regard to a matter of the first im-
portance to the medical world.

It may be urged that the fact of the development of various morbid symp-
toms in connection with pregnancy is an evidence that it may be perfected in
conditions opposed to the normal state. To this I will answer, first, that these
symptoms do not indicate the existence of any serious organic change, but, on
the other hand, they establish the excessive development of the vital principle,
and show that the peculiar state which is most antagonistic to tubercular pro-
gress has been produced to an extent that requires the intervention of nature
to restrain it within proper limits ; and, secondly, that they do not possess any
morbid character when compared with that condition which, in the wisdom of
Providence, they are designed to relieve.

Again, to suppose that a physiological process and a pathological action
require the same conditions for their consummation, and similar laws for their
government, is to convict nature of a contradiction which compromises both
the wisdom and goodness of its author, whilst it precludes the study of natural
phenomena upon rational principles, and prevents all advancement in the
science of medicine. The universal law1 that "nature is infallible, incapable
of contradictions, and has but one plan in her views of organization," has long
furnished the light by which scientific men have conducted their investigations,
and supplied the only certain guide in the attainment of truth. The anta-
gonism between pregnancy and phthisis demands, then, the suspension or arrest
of this disease when the state of gestation is developed.

§ III. It may be affirmed that the proportion of females who die of consump-
tion is greater than that of men, and that there can be no great conservative
influence which operates for their protection. There is, however, no positive
evidence of this fact; and, even if it were true, it would prove nothing in oppo-
sition to my hypothesis. It is true that Louis, Laennec, Papavoine, and Andral
agree that a majority of phthisical cases occur among females, yet Bayie, Clark,
and others have doubted the truth of their conclusions, and furnished statistics
in contradiction of them. The following table is given by Clark: —

At Hamburg, out of 1,000 cases, 555 were males, and 445 females.

Rouen, " 100

Naples, " 697

New York, " 2,954

Genoa, " 133

Berlin, " 620

Sweden, " 3,948

" 6,157

Stuttgard, " 500

56 " " 44

382 " " 315

1,584 " " 1,370

71 " " 62

328 " " 292

2,088 " " 1,860

3,054 " " 3,103

256 " " 147

1 Geoffroy St. Hilaire.

1857.] Warren, Influence of Pregnancy on Development of Tubercles. 117

Dr. Duncan shows from the Registrar's Report, the following facts : Out of
10,000 of the population of London, 828 died of consumption, of whom 457
were males and 371 females, and of the 936 who fell victims to phthisis in
Birmingham, 526 were men and 410 women.

From these tables it is evident that the question of relative mortality is by
no means a fixed one, and that there are good reasons for doubting the conclu-
sions of Louis and Laennec in regard to the subject. In many thousands of
instances at least, a great protecting principle has manifested itself in con-
nection with the female system, and it is evident that without some such
conservative influence the number of women who die of consumption would
far exceed that of men, for the reason that their physical conformation, mental
qualities, moral character, and natural habits, render them particularly sus-
ceptible to the action of those causes whereby phthisis is produced. That
this immunity and protection are due to the effects of utero-gestation is evident
from the following considerations : —

(1.) Pregnancy, as shown before, produces a condition of antagonism in
the economy.

(2.) Pregnancy is a vital process, a high physiological act, and hence its
existence is incompatible with the progress and perfection of a purely morbid
effort.

(3.) Pregnancy diverts the forces and fluids from the lungs, and to the
uterus.

(4.) Pregnancy is regarded by a large majority of medical men, as anta-
gonistic to the march of consumption.

(5.) Pregnancy depends upon the existence of certain susceptibilities which
are inherent in the female system, and hence it is more universal in its ope-
ration than any other imaginable cause.

(6.) Pregnancy, coition, &c, are particularly desired by women affected
with phthisis, which constitutes a pointing of nature towards a remedy for the
evils by which the system has been invaded.

But even if more women than men die of consumption, it establishes
nothing in conflict with the position assumed in this paper.

If the natural predisposition of the two sexes were the same, and the influ-
ences around them identical, then the fact of a greater mortality among
women would demand the interposition of some general cause in the produc-
tion of the unequal result, and pregnancy might be assumed as that cause,
both for the reason that it connects itself with the organ which has the most
important part to play in the female system, and because of the universality
of its operations. But it is entirely unnecessary to introduce any such in-
fluence for the purpose of explaining the inequality of men and women in
regard to the effects of phthisis. It can be explained by a reference to the
natural differences between the sexes, without searching for other causes than
those which necessarily connect themselves with the progress of the disease.

Woman is naturally more delicate than man, whilst her natural suscepti-
bilities to morbific agents are increased by her education, her passions, and
her peculiar habits of life. For these reasons, consumption develops itself
with more facility in their systems than in those of men, and hence, the fact
of their greater mortality can be accounted for, without attributing to preg-
nancy any agency in effecting it. Thus, it becomes evident that though a
greater ratio of women may fall victims to phthisis, pregnancy cannot occa-
sion the difference ; and as a consequence, it follows that the statements of
Louis and Laennec do not contradict the assertions of this paper.

Besides this negative argument, another of a more positive character may
be drawn from these considerations.

118 Warren, Influence of Pregnancy on Development of Tubercles.

There is a natural inequality in the relations which the two sexes sustain
to phthisis, dependent upon differences of conformation and character — plain,
palpable, and conspicuous. An examination of phthisical statistics should
show, then, a decided preponderance of female victims; it should demonstrate
that the difference between the number of women who die of consumption
and the number of males attacked, is as great as their dissimilarity of original
predisposition. The fact that a larger proportion of females fall victims to
phthisis, should be as plain, palpable, and conspicuous, as that they are more
susceptible to those influences which produce the disease. But, as has been
shown above, in a large number of instances the statistics of tubercular affec-
tions prove, that, notwithstanding the original predisposition of women, and
their greater susceptibility to the influences whereby phthisis is developed,
the proportion of victims among males is greater than among females; and
even if these tables do not establish the rule in this matter, they certainly
demonstrate, that so far from its being a fact, plain, palpable, and conspicuous,
that more women die of consumption than men, the whole subject is so in-
volved in doubt and obscurity as to justify the most contradictory opinions,
and to demand much careful attention and patient research for its proper elu-
cidation.

Some agent, then, most potent in its influence, and universal in its opera-
tion, interposes itself for the purpose of equalizing the account between
the two sexes, and making up for their natural differences in this particular.
Pregnancy, as shown above, most completely fulfils all the conditions in-
volved in the existence and operation of such an influence, and hence, it is
proper to conclude, that it is the equalizing cause to which this result is
attributable. I will state the argument more clearly : —

(1.) There is an inequalitjr in the relations which men and women sustain
to phthisis; the former being less liable'to it than the latter.

(2.) This inequality depends upon certain differences of conformation, &c,
which are plain, palpable, and conspicuous.

(3.) An examination of phthisical statistics should show that more women
fall victims than men, and that the difference in the relative mortality of the
two is as plain, palpable, and conspicuous, as their original dissimilarity of
constitution and predisposition.

(4.) An examination of statistics proves, that it is not a settled fact that
more females are destroyed by this malady, and that there is a positive ap-
proximation towards equality in the effects of phthisis upon the two sexes.

(5.) This "approximation towards equality'' shows the operation of some
great equalizing cause, by which a certain amount of protection is secured to
the female system, that makes up for its greater original susceptibility, and
affects the general result in the manner alluded to above.

(6.) Pregnancy complies with all the conditions which this cause demands
for its operation, and it is fair to attribute this protecting, preventing, and
equalizing effect to its influence upon the female system.

I have thus attempted, by arguments, facts, and authorities, to prove — that
pregnancy prevents the progress of phthisis, even when that disease is per-
fectly developed. Whether this effort has been successful, or not, must be
left to the judgment of my readers; and to them I confide my cause, with the
full assurance, not only thct their decision will be equitable in regard to all
that has been urged in support of my position, but that they will agree with
me in the conclusion that, if pregnancy can arrest the progress of consump-
tion when fully established, then, for a still stronger reason must it " retard
the development of tubercles in those predisposed to phthisis."

1857.]

119

REVIEWS.

Art. X. — Statistical Report on the Sickness and Mortality in the Army of
the United States, compiled from the Records in the Surgeon- General's
Office; embracing a period of Sixteen Years, from 1839 to 1855. Pre-
pared under the direction of Brevet-Brigadier-General Thomas Lawson,
Surg. G-en. U. S. Army, by Richard H. Coolidge, M. D., Assistant Sur-
geon U. S. Array. Washington, 1856.

Medicine, as a positive science, can only arrive at perfection, through the
reduction of myriads of the most complex facts to a few simple laws, by the
slow process of careful analysis and laborious investigation ; the work of cen-
turies. To this, none, perhaps, contribute more directly, than those who
obtain and combine accurate and extended observations in regard to the influ-
ence of local circumstances and modes of living, as well as medical treatment,
upon mortality and disease.

In the work which the Surgeon-General and his able assistants have, as a
continuation of a former one, now presented to the country, a vast deal of
matter of this kind, of great value, has been collected. It would be desirable,
in view of the size (a heavy quarto) and comparative inaccessibility of the volume
to many of the profession, to give a full summary of its contents at this time;
but we are diffident of the power to do them justice. A somewhat methodical
survey of the principal matters treated of, will, however, be attempted.

The Statistical Report consists of considerably more than a hundred dif-
ferent papers, transmitted to the Surgeon-General's office by the medical
officers on duty at the several posts, in answer to circulars of inquiry in regard
to medical topography, &c. To these are added abstracts of mortality and
diseases, with copious and elaborate tables, &c. Especial credit is due to
Assistant Surgeon Coolidge for his careful and judicious arrangement of these
various reports, and for the handsome manner in which the volume is got up
and illustrated.

The military posts of the United States have been, for the purposes of this
report, classified into three great divisions, the Northern, Middle, and South-
ern j to which are added, also, those of Florida, Texas, New Mexico, California,
Oregon, and Washington Territories.

The Northern division includes that portion of the United States which
lies north of the fortieth degree of latitude, and east of the Rocky Mountains;
the Middle, all that lies between the thirty-fifth and fortieth parallels of lati-
tude ; the Southern division, all that lies between the thirtieth and thirty-fifth
degrees. We have, in these and the other regions just named, a vast scope
of country, embracing every variety of habitable climate and locality ; from
Fort Kent, in Maine, and Gaines, in Minnesota, at the north, to Fort Brown,
in Texas, and Key West, in Florida, at the south; from 66° 58' to 124° 29'
W. longitude, and from 24° 32' to 47° 15' N. latitude; a range of 57 degrees
in one direction by 22 degrees in the other.

It would be impossible to condense the great number of statements given
in regard to climate, topography, &c, of the various posts, into any limits

120

Reviews.

[July

compatible with the purposes of a review. We shall notice only those which
possess the greatest interest, particularly in a medical aspect. Much informa-
tion of value to the geographer, the geologist, the zoologist, and the botanist,
is also contained in these well-written reports.

In the inhospitable Northern Atlantic Coast Region, but little of etiological
importance presents. The only epidemic in the whole period of sixteen years
upon the coast of New England, at the military posts, was one of catarrh or
influenza, in June and July, 1843. The existence of intermittent and remit-
tent fevers in this region, at some of the forts, is accounted for entirely by the
transfer of troops who had imbibed those disorders in Mexico during the war,
or in Florida at other periods.

" An examination of the abstract will suffice to show the certainty with which
the liability to attacks of intermittent yields to the influence of a residence in
this region, though the fact is more conclusively demonstrated by the original
reports. The troops from Mexico reached the New England stations in Sep-
tember, 1848, and in the following month intermittents are reported, disappear-
ing almost entirely within the succeeding twelve months. In December, 1850,
troops arrived from Florida, bringing with them this class of fevers, which were
eradicated within the following year."

In New York harbour, we find some evidence of the existence of local
miasmata, particularly on G-overnor's Island, among the inhabitants of an
insalubrious place called "Rotten Row." Bedloe's Island, two miles nearer
the ocean, is asserted to be entirely free from malarious influence, notwith-
standing the existence, on the New Jersey side, of extensive salt marshes.

The interest which has lately attached to the vicinity of Fort Hamilton on
Long Island, on account of the occurrence of yellow fever there in 1856,
gives importance to the statements of Assistant Surgeon Eaton, in 1852, in
regard to its topography.

Fort Hamilton is on the southwest corner of Long Island, about six miles
south of New York City, and separated from the Atlantic on the southeast by
a sand-bar of a few rods in width. The wind is said to change there, some-
times, twenty times in the day; a vicissitude which is decidedly prejudicial to
invalids. We quote the main points in the report of Dr. Eaton :—

" The geological construction of the land in the vicinity of Fort Hamilton
renders the topography remarkably singular. From the post towards Brooklyn,
along the North River, the land is generally uneven, and there are numerous
depressions which have the appearance of artificial excavations ; they are gene-
rally four or five rods in diameter, and some of them are very deep and never
dry. More than fifty, I presume, of these depressions might be counted be-
tween the post and Greenwood Cemetery, about four miles north of this. It
may be readily conceived that these numerous stagnant pools, at particular
seasons of the year, may affect injuriously the health of the inhabitants in the
immediate vicinity.

" Eastward of Fort Hamilton, at a distance of half a mile, and extending from
the sea shore to the distance of one mile northerly, and a quarter of a mile
in width, is a low bog or quagmire, called by the Dutch inhabitants " dyker ;"
it receives the surface water from the high lands in the vicinity ; and being
separated from the sea by a sandy beach only, in violent storms the sea makes
a fair breach over the sand, mingling the salt water with the fresh, and, there
being no permanent outlet, the retained water becomes stagnant and putrid.
It must be readily conceived that this is a fruitful source of disease, and in
some locations in the immediate vicinity, to the leeward of the prevailing winds
(S. E. almost every day in the summer) no persons can reside without exposing
themselves to certain and inevitable sickness. There are other low and swampy
lands in the immediate vicinity of Fort Hamilton, the more perfect drainage of
which would contribute much to the health of this location. "

1857. J Coolidge, Sickness and Mortality in U. S. Army.

121

We may observe, therefore, that, however strong the evidence adduced by
Dr. E. Harris and others to show the prevalence of yellow fever in this neigh-
bourhood to have been the result of " ship infection" from the quarantine
station, there is yet enough to make out the existence of local promotive causes
also; especially when it is noted that a higher temperature and greater
humidity than usual prevailed there at the time of the epidemic.

At the different posts in New York harbour, eruptive fevers are said to be
more common than at the other military stations; on account of their being
garrisoned principally by recruits, among whom measles are not uncommon,
and who are sometimes attacked with smallpox before time is afforded for
vaccination. The regulations for the medical department of the army do not
enjoin a uniform system of re-vaccination; they prescribe that "as soon as a
recruit joins any regiment or station he shall be examined by the medical
officer, and Vaccinated when it is required."

Of the epidemics of cholera, influenza, &c, at Fort Columbus and else-
where, we shall take notice hereafter.

Fort Kent, of the u North Interior" region, is the most northern post in
the United States; situated on the St. John's River, in Maine. It affords an
excellent example of a " Siberian" climate ; the mean temperature for the
year ending June, 1845, being 35.90°. The long, dreary winter commences
during the last weeks of October, when repeated falls of snow cover the
ground, to remain unmelted until the succeeding spring. On the 4th of
June, 1844, ice one-third of an inch thick was seen. The last killing frost
in 1845 took place on the 31st of May. White frosts occur repeatedly during
the summer months, and the thermometer, on a clear night with a northerly
wind, sinks to 34° or 33°. These frosts very seldom injure even the most
tender garden vegetables. The transition from winter to summer is very
sudden ; the trees put forth their foliage, and the various plants spring up
with singular rapidity. " I have repeatedly," says Assistant Surgeon Wother-
spoon, " in the woods, found flowers in full bloom, by the side of masses of
the yet unmelted snow." Occasionally, during the summer months, when
southerly or southwesterly winds prevail for two or three successive days, the
weather becomes very warm and oppressive, the thermometer rising to 94°
or 95° in the shade ; but generally it is sufficiently cool to wear the ordinary
winter clothing of warm climates. The prevailing winds are from the W.
and N. W. It is the southerly and easterly winds that bring the heavy
rains.

Notwithstanding the rigor of their climate, the settlers on the St. John's
River, mostly of French origin (descendants of the Acadians), are stated to
marry at a very early age, particularly the females — as at 13 and 14 years.
Some of the families are rather remarkable in point of numbers. Twelve,
living within a mile of the garrison, and taken without exception, have had
in all, 93 children. One man had 26 children by one wife; the mother hav-
ing her last infant at 53 years. Another, had 19 children in 18 years; five
pairs of twins. A third, in three successive years, had three twin births ;
and all of the children lived : and other remarkable instances are given. The
women often leave their beds twenty-four hours after delivery ; and, in con-
sequence of this and rapid child-bearing, are most of them subject to prolap-
sus uteri and leucorrhoea.

In 38 cases, the average date of the first appearance of the menses was
13.5 years. In 8 American girls raised on the river, although accustomed to
more comfortable living, warmer clothing, and more stimulating food, the

122

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[July

average was 15.12 years; so that race, as well as climate, has decided influ-
ence.

During the fall, winter, and spring months, the forest near the St. John's
becomes peopled by a floating population of lumbermen, whose number varies
from 2,000 to 3,000. After the rivers open, in April, many of these are
engaged for two or three weeks in setting the logs free in the streams, with
their lower limbs constantly, from sunrise to sunset, immersed in water of a
very low temperature. They lie down at night, weary, without changing
their clothes, by a camp-fire, or on the floor of a hut. From this exposure,
chronic or subacute rheumatism often results; but, during two years of obser-
vation by Assistant Surgeon Wotherspoon, only two cases of bronchitis oc-
curred, and none of pneumonia or pleurisy. The region of Fort Kent is
considered to be one of the healthiest in the United States; fevers, and other
diseases of malarious origin are unknown ; and other acute diseases are not
common. A marked freedom from catarrhal affections is observed. On this
subject, Dr. Wotherspoon remarks : —

" This is no doubt owing in great measure to the peculiar dry bracing atmo-
sphere of this region. While on the sea-coast, I found that catarrhal diseases
originated not so much from sudden vicissitudes of temperature, as from a
simultaneous change in the hygrometric condition of the atmosphere. A sud-
den change from a comparatively dry and warm westerly or northwesterly
wind, to a cold damp air from the northeast or east, was certain to send its
quota of sick to the hospital, with the various forms of catarrhal disease ; while
an equally sudden change from a warm southerly, to a cold northwesterly, was
unattended by the same results."

The climate of Fort Kent, like that of the colder regions of northern
Europe, does not seem favourable to the production of pulmonary phthisis.
Dr. Wotherspoon never saw or heard of a single case among the French or
American settlers. Assistant Surgeon Tsaacs, while living two years at the
fort, not only never saw a case in the country, but asserts that some of the
inmates of the garrison, affected with suspicious symptoms, recovered from
them entirely. Children in and near the garrison also enjoy the best of
health, being afflicted with none of the diseases common in warmer climates.

Goitre is, however, not an uncommon complaint in the settlement; attack-
ing, here, as elsewhere, mostly females, after the age of puberty. Twenty-
five years since, it was much more prevalent than now. It is supposed by
the inhabitants to originate in the use of the river water ; but the same water
has been freely used by those living on the lower St. John's, and yet a case
of bronchocele has never been seen below the Grand Falls. It has attacked
the American settlers as well as those of French origin. In one young
American girl, aged 15, it appeared after she had been in the country about
a year; in two others, after they had lived on the river a longer time. In
two of these cases, the disease was cured by a removal from the country. In
looking at the topography of this region, as described, it is difficult to see
any marked peculiarity to which to refer the tendency to this disorder. The
whole country is, it is true, intersected by chains of hills, running from W.
to E., of a height varying from 200 to 600 feet above the level of the river;
and, in the valleys between these, densely wooded, until cleared for farms,
the inhabitants, no doubt, live. But the streams are rapid, and hygrometrical
observations would seem to indicate that, in general, the atmosphere around
Fort Kent is unusually free from aqueous vapours.

A similar salubrity, especially as regards the absence of consumption, is
reported of Fort Fairfield, on the Aroostook River, 200 miles from the ocean.

1857.] Coolidge, Sickness and Mortality in U. S. Army.

123

And in regard to Hancock Barracks, with a mean annual temperature of
40.15°, Assistant Surgeon Sprague remarks, that

" This station surpasses most others in its freedom from sickness. Cold as
the winter is, and damp as the autumn and spring are rendered by frequent
rains, persons who have suffered from weak chest find their complaints much
mitigated by a residence here. Consumption is rarely seen among the inha-
bitants of the town, and many persons, who were predisposed to that disease,
have continued in good health, free from cough, and have had their constitu-
tions invigorated and improved. "

West Point, on the west bank of the Hudson, latitude 41° 23', is well
known to be a remarkably healthy spot. " From December to March, par-
ticularly in the coldest, and, of course, driest winters, it often occurs that, out
of eight hundred persons, there is not, for weeks together, one seriously sick."
A high ratio .of reported cases of disease occurs, however, on account of the
command at West Point consisting almost entirely of cadets, who are often
registered for very slight indispositions.

At Watervliet Arsenal, a malignant epidemic of erysipelas, " with also
many cases of puerperal fever, nearly all of which proved fatal," prevailed in
June, 1841. In 1842, a similar disorder spread over the northwest part of
Vermont, along the New York border, and in the counties of the latter State
bordering on Lake Champlain. It reached Plattsburg by March 31st; and
continued without much mitigation until the summer of 1843. In the latter
place, notice is especially taken by Assistant Surgeon McPhail, of the coin-
cidence of fatal puerperal fever with the epidemic.

In the "Region of the Great Lakes" we find, without many degrees of
change of latitude, much more evidence of the prevalence of endemic dis-
eases than in those just reviewed. At Madison Barracks, near Lake Ontario,
N. Y., a question of interest is raised, by Assistant Surgeon Henderson, as to
the cause of the unusual amount of sickness, chiefly diarrhoea and remittent
fever, in the summer of 1839. As compared with other years, that season
was "cool and seasonable as to rain." No local or -hygienic difference could
be discerned except that, " within a few years, the lakes have risen between
three and five feet, and are now falling." Dr. Henderson does not consider
that this laying bare of a few inches, annually, of lake shore, or the draining
of tributary streams, can have much to do with the sickness. Surgeon H. L.
Heiskell agrees with him, especially as "the lake shore in this vicinity is
generally bold and rocky;" and suggests the ill-ventilation of the barracks as
a cause of disease. Dr. Henderson, however, shows that although still imper-
fect in ventilation, the company-rooms were much better in this respect in
1839 than in 1838, when there was little sickness. More recent investiga-
tions, in New Orleans and elsewhere, would seem to prove that the popular
view, in regard to the insalubrity of newly exposed soil, is probably correct, in
pite of theoretical objections.

At Fort Ontario, in the city of Oswego, on Lake Ontario, but 50 or 60 feet
above it, and 290 feet above the level of the sea, intermittent fever prevailed
in 1842; since that time, it has almost entirely disappeared.

At Detroit Barracks, and at Fort Gratiot, near Lake Huron, autumnal
fevers exist; being favoured, in both instances, by the neighbourhood of
" sluggish streams and frequent broad marshes."

Fort Mackinac, on the island of Mackinac, 728 feet above the level of the
ocean, is stated to be one of the most healthy in the United States.

At Fort Wilkins, near Copper Harbor, on Lake Superior, an epidemic of
peritonitis occurred in the winter of 1844-45.

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Reviews.

[July

" Although only thirteen cases were officially reported among the soldiers,
many of the command were affected with premonitory symptoms, such as nausea,
weight, and oppression at the epigastrium ; sometimes griping, burning pain,
diarrhoea, and occasionally bloody discharges. Again, there were pricking,
tearing, lancinating pains in the abdomen, with tenderness on pressure. Yet
many of these cases were so checked, by promptly resorting to remedies, that,
not running out their course, they were not reported ; nor were some severe
cases in the families of officers reported on the sick-list. One case, that of a
soldier, terminated fatally. The disease was marked by great severity of symp-
toms, by their proneness to recur, and by unusual obstinacy and resistance to
the action of remedies. The plan most effectual to arrest premonitory symp-
toms was, abstinence from all food, counter-irritation, sinapisms, and hot appli-
cations to the abdomen ; small doses of mass, et hydrarg. cum opio, followed by
cups, pediluvia, and enemata. If the disease did not rapidly yield, copious
bleeding, followed by cupping, calomel, and opium in doses to act gently on the
liver and intestinal canal, and to relieve pain, were the appropriate means. I
found it necessary," says Assistant Surgeon Isaacs, " in most cases, to repeat
bleeding and cupping three or four times. In the latter stages blisters were
used. In the first two cases only did I think it necessary to touch the mouth
with mercury, and it is questionable whether it was of any service. The dis-
ease in its last stages had a strong tendency to pass into dysentery. From the
symptoms and aspects of all the cases carefully considered, and from the post-
mortem developments in the one fatal case, the disease seems to have been an
obstinate and intense peritonitis ; the inflammation in the latter stages involving
the mucous coat of the stomach to some extent, of the small intestines, but par-
ticularly that of the colon."

The cause of this singular affection was unknown. Endemic atmospheric
agency seemed probable, as a similar form of disease prevailed at La Poiute,
180 miles west of Copper Harbor, four years before, destroying about thirty
of the inhabitants. This was also in the winter.

At Fort Winnebago, in the " North Interior region, west of the Great
Lakes," Surgeon Lyman Foot observes : —

" One thing I think remarkable here ; complaints of the lungs, phthisis in all
its forms, are less common here than at any post at which I was ever stationed.
How shall we account for it ? Is it the dry atmosphere ?"

Of Fort Dodge, in the northwest corner of Iowa, latitude 42° 28', Assistant
Surgeon Keeney states, that —

" Most of the diseases of the respiratory system were of the mildest nature,
and in the majority of the cases were unaccompanied with febrile action. The
only diseases of the chest, involving the substance of the lungs or pleura, were
imported cases. The mildness of the diseases of the thoracic organs may also
be attributed to the general dryness of the atmosphere during the great thermo-
metric changes."

These changes are described as being sometimes extreme ) not merely
rigorous from the low degree of temperature but from —

" Hurricane winds that rushed from the north and swept over the prairie,
chilling the innermost blood both of man and beast. During January, 1852,
the mercury fell to the lowest graduated degree of our thermometers, namely:
28o below zero."

In June, the temperature is sometimes 97° in the shade. These changes
are attributed to the fact, that at the north, south, east, and west, all is one
vast stretch of prairie, with no great body of water to modify the influence of
the winds. During the greater part of the summer months there are no
clouds to parry off the piercing rays of the sun. " The atmosphere is exceed-

1857.]

Coolidge, Sickness and Mortality in U. S. Army.

125

ingly dry at all times." Remittent and intermittent, nevertheless, prevail at
this post.

"I am prepared to state," says Assistant Surgeon Keeney, "that all the
remittents and intermittents that have occurred at this post were caused by
the imbibition and absorption of miasmatic poison generated by the vegetable
decomposition in the bottom lands, where gardening and farming have been
carried on. Nearly all the men who have been the subjects of these fevers
were the ablest bodied men of the command, and, when on other duty in the
uplands, enjayed perfect immunity from those fevers; but no sooner would they
be detailed for horticultural duty than they would report sick with one of these
fevers."

The dryness of the atmosphere is said, notwithstanding the great vicissitudes
of heat and cold, to induce a great rarity of rheumatism at this post.

Although not intending to dwell upon the Natural History or Botany of
the volume before us, we may notice one curious problem for the vegetable
physiologist, as it is described by Dr. Keeney : —

" There is one plant everywhere to be found on the prairie that at all times
attracts the attention of the traveller, not only from its height and brightness
of flowers, but because its leaves are endowed with peculiar qualities. It is
the compass or polar plant (silpliiv.m laciniatum). It is a plant that grows from
one to five feet high, rather coarse in its general aspect, and with a ferny leaf.
The flower is like that of the sunflower. This plant is celebrated for the pecu-
liar property of its leaves, pointing due north and south. Some have said the
leaves do not always point north and south, but go with the wind. From many
and careful observations, I can say that its polarity can be as much relied on
as the magnetic needle.

"I have often seen the stock bent near to the ground by the force of the winds
while the leaves were still pointing north and south.

"The magnet reveals none of its secrets, nor does dissection. But still I am
inclined to think that its polarity is dependent on magnetism, influenced by the
action of light on its leaves."

The following account is given, by the same writer, of a useful article of
prairie diet: —

" It supplies the place of both bread and meat, and, for its remarkably nu-
tritious qualities, ease of digestion, and for the great facilities of transportation
which the compactness and small bulk of the article afford, it is well worthy
the notice of the department. It is called pemican. It is composed of buffalo
meat and buffalo tallow. The buffalo meat is first thoroughly dried in the sun,
and then pounded until it is about the consistence of meal ; the tallow is melted,
and freed from all impurities, and then poured on the meat and well stirred —
the proportions should be about equal, or a little more tallow than meat. The
mixture, being well stirred, is then poured into sacks made of untanned buf-
falo hide, and allowed to cool ; no salt is used — probably to prevent thirst.
"When properly made, it will be perfectly good at the expiration of a year.
This article is used almost entirely by the fur traders of the Hudson Bay and
American Fur Companies as their only food when travelling." " Fifteen
pounds would be an ample allowance for a soldier on a twenty days' march,
carrying with him, at the same time, his musket, his knapsack, and his pemi-
can. I can conceive no other article of diet to be so invaluable to the soldier
as the above, where transportation is limited, and difficult marches are to be
made."

At Fort Ripley, on the Mississippi, in Minnesota, latitude 46° 10' 30" N.,
the climate is subject to great variation as well as rigor. The extremes of
temperature noted are 96° in August, and — 39° in January. A change of
30 or 40 degrees in a few hours is not uncommon. Here, as in northern
Maine, when spring has once begun, the region seems to pass with great
No. LXVIL— July 1857. 9

126

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[July

rapidity from the climate of winter to that of midsummer. No miasmatic
diseases originate in this locality. Dysentery has occurred to a serious ex-
tent, particularly in the summer of 1851. "Notwithstanding the absence of
numerical bases, and of a sufficient number of facts upon which to found
general deductions, the opinion may be ventured," writes Assistant Surgeon
J. F. Head, "that the ratio of infantile viability will be found extremely low
throughout Minnesota." We cannot help hoping that this is a conclusion
based upon a temporary prevalence of disease, which may be essentially mo-
dified by extended observation.

In connection with Assistant Surgeon Head's Report, an interesting account
of the Indian tribes of Iowa is given, as prepared by Dr. David Day. We
may make this the occasion to condense some of the most important facts, of
a hygienic and sanitary character, in regard to the Indians, which are scat-
tered through this volume. Twelve of the reports, by different authors, give
the results of their personal observations upon more than twenty different
tribes,1 carried in some instances through several years. We mention this, to
show the authority for the positive assertions they contain ; which conflict
somewhat with the popular idea of the salubrity of a " state of nature," as
savage life is inappropriately called.

The squaws, who do all the work, are in several places spoken of as more
muscular and better developed than the men. Their child-bearing, neverthe-
less, is not untroubled. "Child-bearing," says Assistant Surgeon Moses,
" among the Indians, is a no more easy nor less dangerous process than among
other females in the same circumstances in life." " An Indian woman,"
writes Dr. Day, u can no more violate with impunity the obvious hygienic
treatment necessary in the parturient state, than can a white woman."

" It is wrong," observes another reporter, " to suppose Indian children better
capable of surviving less careful treatment in infancy than are those of the
■whites. The former are generally born with less vigorous constitutions than
the latter. The 'hardening process' kills multitudes of them." " They mostly
die in infancy."

All the reporters agree in regard to the great mortality among the Indians,
at all ages and under all existing circumstances ; and the most melancholy
part of this is, that it seems to be the contact with civilization which induces
their speedy decay. The vices of the pale-face are more contagious than his
refinements ; his diseases more easily transferred than his remedies. The great
scourges of the Indian tribes are, smallpox, syphilis, and intemperance ; all
borrowed from their white neighbours. Besides these, they die also rapidly
of measles, cholera, pneumonia, dysentery, remittent, and intermittent fevers.
G-onorrhoeal ophthalmia is exceedingly common. Dr. Day's summary is as
follows : —

" By comparing these results with the vital statistics of other races, we find
that the ratio of mortality is much higher among these Indians (Winnebagoes)
than in the white race, and considerably above that of the negro population
of the United States ; the rates of mortality in Great Britain being 1 death in
44 inhabitants ; in Massachusetts, 1 in 35.30 (Eighth Report to the Legislature
of Massachusetts relating to the registry of Births, &c.) ; in Philadelphia, 1
in 43.12 of the white population, and in the coloured, 1 in 31.05 (Emerson on
Vital Statistics of Philadelphia). In Baltimore, the average ratio of mortality
is, in the white population, 1 in 46.40; in the free coloured, 1 in 34.17; while

1 Winnebagoes, Ojibways, Sioux, Osages, Pawnees, Kickapoos, Choctaws, Chicka-
saws, Ckerokees, Creeks, Caddoes, Wakoes, Tonkiways, Witchetas, Comanckes, Li-
pans, Navajoes, Chinooks, Clatsops, Cathalemets, &c.

1857.] Coolidge, Sickness and Mortality in V. S. Army.

127

in the slave population, it amounts to 1 in 26.59 (Joynes, Stat, of Mort. of Bait.,
Am. Journ. of Med. Sci., Oct. 1850). The rate of mortality among the Winne-
bagoes, and that of the slave population of Baltimore, as given by Dr. Joynes
(which, I believe, does not materially differ from that of the same population
in other American cities), are very nearly the same." " The proportion of mor-
tality is much greater among children than appears to exist elsewhere in child-
hood. In Great Britain, 35 in every 100 deaths are under 10 years of age ; in
Philadelphia, 56 per cent, are under 21 years ; and in Baltimore, 58 per cent. ;
while, among these Indians, those dying under 15 years amount to 70 per cent,
of the total mortality." " Cases of extreme longevity, however, are not rare
among them." " This is in accordance with the fact, that that class of a popu-
lation haviDg the shortest life in the aggregate, furnishes the most cases of
extreme longevity in proportion to its numbers."

In Kansas, Assistant Surgeon Barnes states the number of the Osages to
have been, in 1845, 6,000 ; in 1850, 5,000 ; in, 1852, 3,500. The destruc-
tion from smallpox alone, has been sometimes tremendous ; sweeping off the
half, or more, of a tribe, in one epidemic. This is easily credited, when we
remember, that, in G-reat Britain, before the time of Jenner, in a population
of eight millions, the deaths, per annum, from smallpox, were thirty or forty
thousand. Such facts should answer all skepticism in regard to the value of
vaccination. Typhoid pneumonia, or the " winter fever," destroys the Indians,
also, in great numbers ; and phthisis is very common and fatal.

When an Indian is seriously sick he is almost sure to die. They have few
remedies. The report of their having a cure even for the rattlesnake's bite
seems to be without foundation. Venesection (without much choice as to the
vein or instrument), local scarification, and the vapour-bath, are their princi-
pal means of treatment of disease. But the main reliance is always upon
the conjurations of the " medicine-man." This prophet-doctor endeavours
to exorcise the malady by spells and rites; if he fails, in some places at
least, he forfeits his life ; unless he can purchase it, with an equivalent of
baubles and blankets.

Beturning, now, to our inspection of the local reports, Assistant Surgeon
G-. K. Wood, at Fort Laramie, in Nebraska, lat. 42° 12' 38", makes the
following remarks : —

" The climate of those broad and elevated table lands which skirt the base
of the Rocky Mountains on the east, is especially beneficial to persons suffering
from pulmonary disease, or with a scrofulous diathesis. This has been known
to the French inhabitants of the Upper Mississippi and Missouri for many
years." " The reports from the line of posts stretching from the Upper Platte
through New Mexico to the Rio Grande, give a smaller proportion of cases of
pulmonary disease than those from any other portion of the United States.
The air in this region is almost devoid of moisture ; there are no sudden changes
of temperature ; the depressing heats of the eastern summers are never ffelt ;
and, although in the north the winters are extremely cold, a stimulant and
tonic effect is the only result of exposure in the open air. It is of great im-
portance that the climate of this region should be generally known, that the
present injudicious course of sending consumptives to the hot, low, and moist
coast and islands of the Gulf of Mexico should be abandoned." " The towns of
New Mexico should be selected as a refuge for those showing a tendency to
disease of the lungs, or scrofula, anywhere east of the Rocky Mountains, and
west of the region where ■ northers' prevail."

Coming next to the " Middle Division," at Fort Washington, on the Poto-
mac, Assistant Surgeon Edwards observes, that intermittent and remittent
fevers, always endemic, have decreased in prevalence within a few years. The
cause for this is unknown.

128

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[July

At Fort Monroe, on Old Point Comfort, "Virginia, the terminus of the
western shore of the Chesapeake, the characteristic of the climate is de-
scribed as being humidity. In the language of Surgeon Stinnecke : —

" The existence of this altered or modified condition of local atmosphere is
distinctly visible in its checking the advances of spring, by retarding the action
of all physical agencies ; in the development and growth of vegetation, when
compared with that of surrounding districts ; in the rapid and large accumu-
lation of mould on all articles susceptible of imbibing moisture ; in weakening
and relaxing the animal tissues ; and in exalting the impressibility of the entire
system. In a practical point of view, professionally considered, the most im-
portant consequences of these peculiarities of air are the tendencies (noticed)
to affect the animal tissues ; tendencies manifested in the frequent induction
(and obstinacy when induced) of certain of the profluvia, such as leucorrhoea
and menorrhagia. Similar pathological conditions, and referable to like causes
(humid air), are, we believe, noticed as pertaining to the coast of Holland."

Dr. Stinnecke also refers to the alterative properties of the " marine air"
of the locality, considering that, for therapeutic effect upon invalids, the stay
at such places is usually not sufficiently long. Fort Monroe, unlike the neigh-
bouring country,-is entirely free from miasmatic disease; and it is thought
worthy of note, that, in four years, not a single case of any of the exanthemata
has occurred ; although prevailing, at times, no further off than Norfolk, dis-
tant but fifteen miles.

In the region farther west, one of the most unhealthy posts in the country
is at the St. Louis Arsenal. It is at the lower end of the city of St. Louis,
and nearly surrounded by shallow water, in which animal and vegetable re-
mains often accumulate. Intermittent fever is the prevailing disease. At
Jefferson Barracks, ten miles lower on the Mississippi, the same endemic
exists. " At least three-fourths of the persons at the post," says Surgeon
De Camp, "have had fever this season (1839); while at the distance of one
mile from the river, a dense forest intervening, there has scarcely been a sin-
gle case."

Forts Scott and Atkinson, in Kansas,1 give us examples of & prair ie country
and its climate. The site of the former is particularly "open and unconfined."
It is on a spur of table prairie land, about 1000 feet above the level of the
ocean.

" Owing to the physical conformation of the country, the climate is one of
extremes of heat and cold, of dryness and moisture. After a long and debili-
tating summer, the winter, most frequently commencing abruptly with cold
storms from the N. E., is a succession of alternations, the mercury falling or
rising 30° to 40° in a few hours." " There are no grass-ponds, swamps, or
lakes near us ; the streams are numerous, but without stagnant pools ; the
bottom-lands extensive, and sometimes overflowed, but they drain as rapidly
and thoroughly as the prairies."

And yet, of 3,415 cases, in about seven years, in a command of 3,034 men,
1,717 were malarious fevers. We must look for the cause of this preponder-
ance, to use the expression of Assistant Surgeon Barnes, to the " general cha-
racteristics of rich prairie country;" which vary, in a striking manner, with
the influence of different seasons. A predominance of the weed-growth over
that of the gramineous plants is believed by Dr. Barnes to be an important
source of comparative insalubrity.

" The time of the spring rains affects the growth of these prairies much more

1 Or, as enumerated in another part of the volume, the former in Missouri, the latter
in Iowa.

1857.]

Coolidge, Sickness and Mortality in U. S. Army.

129

than the quantity, and upon a supply of moisture at a certain period the vege-
tation of the year will principally depend. In an ordinarily productive and
healthy season the spring rains commence in April, and do not continue be-
yond the middle of May ; the weeds and grasses shoot up rapidly, are fully
matured in July. Desiccation commences in August, and in September the
horizon becomes smoky from numerous fires, which, extending, sweep off the
greater portion of the year's growth. Should, however, the spring rains not
set in until June or July, the weeds will have withstood the drought better than
the grasses, and will then start into rank luxuriance, the prairies remain green
until late in the fall, and the winter rains commence before desiccation is com-
pleted or the surface burned over. That the growth, as well as the decay of
this vast amount of vegetable matter, spread over the entire region so controlled,
generates a malarial influence, either by the evolution of miasma, or, as is most
probable, by the development of organic germs (cryptogamous growths in such,
seasons being inconceivably abundant), can hardly be questioned. The epi-
demics of 184S, 1845, and 1851, commenced while the prairies were still clothed
with verdure, and reached their acme before decomposition was established;
the striking feature of resemblance in these seasons being the lateness of the
spring rains." " The oldest residents of the country look to the early com-
mencement of the spring rains as the harbinger of a healthy summer and fall,
and vice versa."

Dr. Barnes bas noticed, also, a marked relation between the prevalence, in
winter, of diseases of the respiratory organs, and the pre-existence of malarious
fevers. " Among the country people, a severe winter following upon an epi-
demic of intermittent produces much mortality; for, either through the debili-
tating effect of long exposure to malarial influences, or a predisposition induced
directly by them, pneumonia, pleuritis, and pleuro-pneumonia usually assume
a typhoid form." This important statement is confirmed by the accounts of
the fatality of the " winter fever" or u typhoid pneumonia" in many of the
reports from malarious regions, as in those of Assistant Surgeons Coolidge,
Glisan, Crawford, and Anderson. The following is the description of the
disease given by Assistant Surgeon Coolidge, while stationed at Fort Gibson,
Indian Territory : —

" The most fatal disease occurring in the vicinity of Fort Gibson, and also in
the State of Arkansas, is that called, in the language of the country, ' winter
fever/ The principal mortality among the Cherokee and Creek Indians is from
this disease. It usually attacks persons enfeebled by climate and malarial in-
fluences, who live in open houses, are poorly clothed, and, above all, intempe-
rate. No case has occurred, to my knowledge, among the regular troops. The
disease is sometimes rapidly fatal, being ushered in with a chill, during which
the brain or lungs, or both, become fatally congested, the patient never rally-
ing. In less severe cases there is usually a chill, followed by fever, complicated
with pneumonia, which is not unfrequently double. The disease has a strong
tendency to become typhoid, and, if treated as an ordinary pneumonia, is gener-
ally fatal." " It appears to be an - essential fever/ with inflammation. In
such cases my observation teaches me that you may bleed, cup, give mercurial
cathartics, and use the tartrate of antimony freely, and still the disease will
gain ground." " In this condition, with extensive inflammation of both lungs,
I have given the sulphate of quinia in ten and twenty grain doses, with the
happy effect of removing almost entirely the attendant fever in less than twenty-
four hours, and checking, or at least enabling remedies, before inefficacious, to
check the progress of the disease."

In a subsequent report (March, 1847), the same writer observes : —

" I have had an excellent opportunity this quarter of treating this disease
('winter fever'), in a severe form, among the Arkansas volunteers, and the suc-
cess of my treatment has corroborated the views expressed in my report for
December, 1845, The treatment adopted was moderate bleeding, cupping, and

130

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[July

external irritants ; a mercurial cathartic, followed by the nitrous powder of the
JJ. S. Dispensatory, frequently repeated, and quinia given in sufficient doses to
check the fever, which it always did. The disease had a typhoid tendency,
which prevented large bleeding, and rendered the use of serpentaria, senega,
and wine, necessary in the latter stages. Sixteen eases were treated this
quarter, two of which were fatal; of these, one was apoplectic when first seen ;
the insensibility was never removed, the patient dying in sixty hours. The
other was complicated with meningitis, and was under treatment only thirty-
six hours."

At Fort Atkinson, on the Arkansas River, Assistant Surgeon Ridgely,
while noticing the great comparative frequency of diseases of the digestive
organs, observes that —

" This is in striking contrast with those of the respiratory organs. I can
only attribute this almost entire immunity from intra-thoracic disease to the
great dryness of the atmosphere which usually characterizes this portion of
' the Plains/ "

Assistant Surgeon Barnes gives us, at Fort Riley, Kansas, in 1853, an in-
stance of vegetable decomposition occurring on a large scale during the sum-
mer, in latitude 39°, without the origination of a single case of malarial fever.
After the 20th of May—

" Large quantities of timber were cut in the bottoms, leaving the ground
cumbered with decaying tree-tops, branches, and foliage, without any percep-
tible effect on the health of the troops ; the parties at work near the river being
quite as free from disease as those at the quarries. The dryness and equable
(although high) degree of heat during August and September, doubtless tended
materially to this exemption."

We are brought, now, to the " Southern Division/' between the 30th and
35th degrees of latitude. In the " South Atlantic" region, four military sta-
tions are included ; of which only two are permanently occupied — Oglethorpe
Barracks, at Savannah, and Fort Moultrie, on Sullivan's Island, Charleston
Harbor. The following brief description is given of the topography of the
former locality : —

" Savannah is distant about 12 miles, in a direct line, from the ocean.
Situated upon a sandy plain, elevated about 40 feet above low-water mark,
this city stands upon the southern side of the river of the same name. This
ridge extends upwards of a mile along the river, terminating abruptly. At the
depth of twenty or thirty feet, fine water is obtained. The city is bounded on
the east and west by alluvial soil, called, in the language of the country, tide
swamp ; being subject to inundations by the ordinary spring tides. It is, con-
sequently, well adapted to the cultivation of rice. The city, divided by numer-
ous and wide streets intersecting each other at right angles, is open and spacious ;
and, being planted with the pride of India (melia azedarach), the long-continued
heats of summer, moderated by the sea-breeze, prove less oppressive than in
some more northern towns."

An elaborate report, the longest in the book, is contributed by Surgeon J.
B. Porter, on the medical topography and diseases of Fort Moultrie and Sul-
livan's Island. It contains much matter of great interest, especially in regard
to yellow fever ; but the readers of this journal have been already made ac-
quainted with its facts, through the papers by the same author, not long since
published.1 We may barely recapitulate a few of the main points insisted
on. These are— 1. The indigenous origin of yellow fever at that locality,

1 Am. Journ. of Med. Sci., July and October, 1854 ; January, April, and July, 1855 ;
October, 1856.

1857.] Coolidge, Sidcness and Mortality in U. S. Army.

131

and its non-contagion. 2. The terrible increase of fatality given to yellow
fever by intemperance. 3. The employment of quinine, in free doses, with
calomel in its treatment. Ptyalism was thought to be always a favourable
sign. 4. The occurrence of febrile epidemics, bearing a more or less near
resemblance to yellow fever. Thus, in the fall of 1850 : —

" The epidemic disease was mostly southern bilious remittent fever ; some-
times continued fever, with tendency to congestion. But I do not

hesitate to say that the disease made a near approach to yellow fever."
<; Everything considered, it is my opinion that only ' one more turn of the
screw' was wanting to develop well-marked yellow fever."

We quote this in order to compare with it one or two expressions used by
other reporters. Assistant Surgeon Moses, at Ringgold Barracks, in Texas,
1854, remarks : —

"On my arrival, I found the same disease prevailing which had existed at
Fort Merrill ; a malarial fever of unusual severity. The disease, soon after, in-
creased in intensity, and attacked a large majority of the garrison, and nearly
every soul in the adjoining village ; appearing in the different degrees from
ordinary fever and ague to a low congestive form of remittent, closely approach-
ing yellow fever. Along the banks of the Nueces and Rio Grande, few escaped
between Lareda and Brownsville ; while at Monterey, Saltillo, and Mier, in the
interior, the disease was comparatively mild ; at Corpus Christi, on the other
hand, it was of greater severity, and assumed the form of black vomit, or true
yellow fever."

Again, Assistant Surgeon Hammond, Barrancas Barracks, in Florida : —

"This case," described in the report, "affords a fine instance of yellow fever.
Its subsidence through the different forms of miasmatic fever, as the cause was
removed, not to say eliminated, and as circumstances permitted the latter to
produce a sensible effect, is perceptible ; and the peculiar influence of sulphate
of quinia in malarious fevers is evident. The tendency of the fever to return
in an intermittent form, was observed in many of the other cases of yellow
fever that recovered."

These facts admit, of course, of explanation upon either of two theories;
that of the essential identity of all southern fevers, yellow fever being only
a high grade of bilious remittent — the view which Chervin urged, and to
which Dr. Rush inclined — or, that of the blending and conversion of types
of fever, which are specifically distinct; as elegantly expounded by Prof.
Dickson. With the majority of the profession, we prefer the latter view;
but the facts are such as ought not to be overlooked.

Cholera infantum is said to be indigenous on Sullivan's Island ; and it is
mentioned as an example, also, in a comparatively warm climate, of a locality
quite unsuitable to patients with chronic bronchitis or phthisis ; the mortality
from the latter disease being high, as might be anticipated, from the " hot
climate, humid atmosphere, and high dew-point."

In the accounts from the " South Interior" region, we are made familiar
with the most peculiar feature of southern climates — the alternation of the
dry and "rainy season." At Fort Jessup, Louisiana, "the summer usually
commences about the 1st of May, and continues until the last of September."
a The rainy season commonly begins in the month of February, and con-
tinues until the first or middle of May, with intermission." Malarial fevers
of all types abound in this section of country; which includes the States
of G-eorgia, Alabama, Mississippi, and Louisiana.

The attention of the profession has been often concentrated upon the city
of New Orleans, on account of its fatal epidemics. We extract, from the

132

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[July

work before us, the following sketch of its chief atmospheric habitudes, by
Surgeon Hawkins : —

" The S. W. and S. E. winds prevail during the five months from April to
August, and the N. E. in September. It is to be remarked that the E. N. E.
and S. E. winds come from the Gulf of Mexico, over an immense tract of low
swamps, and that the prevalence of N. and E. winds in July, August and Sep-
tember, is always attended with the epidemic yellow fever. In fact, these three
months are the only ones that can be considered as proper seasons of disease —
that is, the cause of yellow fever is produced during those months. Its ravages
may, and do, extend into October; but when there has been no epidemic during
August and September, strangers are not as liable to disease in October. It
has also been remarked, that during an epidemic — for example, in September —
if the wind prevails steadily for a few days from the S. W. or W., the disease
seems to be checked, fewer new cases occur, and those who are sick recover
more readily. If, after this state of things, the wind shifts around again to
the N. E., the disease resumes its virulence, cases occur more frequently, and
those who are convalescent are suddenly thrown back and frequently succumb.
The yellow fever in this climate, then, may be traced to the following combined
causes : 1. Low stage of water in the river, leaving its banks, with the de-
posits brought from the upper country, exposed to the action of the sun ; 2.
Decomposition of vegetable matter in the swamps in the rear of the city ; and,
3. The prevalence of E. and N. E. winds. These winds come not only loaded
with miasmata from the swamps which they traverse, but are cold, and tend
to produce chills, rendering the system more liable to be impressed with other
causes incident to the climate, such as sudden alternations from cold showers
to a burning sun. In confirmation of this opinion, it is remarked that a con-
trary state of things — to wit, high stage of water on the river, and the preva-
lence of S. "W. and W. winds — is not attended with epidemic fever."

Assistant Surgeons McParlin and Hammond, amongst others, give very
interesting accounts of epidemics of yellow fever — the former at Pascagoula,
Mississippi, in 1853, and the latter at Barrancas Barracks, Florida, in the
same year. Both of these gentlemen, and especially Dr. Hammond, state the
greater liability to attacks of those brought into frequent connection with the
sick; as attendants in the hospitals, &c. Says Dr. H. : "The apparent con-
tagiousness of the disease was a subject of general remark, and not a ques-
tion." Of several who have, in this volume, reported at greater or less
length on yellow fever, these are the only writers who hold this opinion. We
need not comment upon the possibility, so largely discussed of late, of a quite
opposite construction being (by those who hold different views) honestly
placed upon the very same facts; nor upon the recently urged opinion, which
seems to harmonize many conflicting reasonings upon this subject and on that
of cholera, that the occasional personal conveyance of the causa causans of
disease may be rationally explained otherwise than by absolute contagion.

The gentlemen above named concur with Surgeon Porter, as to the success
and comparative merits of the use of calomel and quinia, in full doses, as the
main part of the treatment of yellow fever. Agreement upon this point
seems to have been quite general, although not without exception, among the
medical officers of the army, at the period of the preparation of these reports.

The impossibility of substituting any known remedy for sulphate of quinia
(cinchonia, quinidia and quinoidine not being amongst the army supplies) in the
treatment of autumnal fevers, is testified to, after compulsory trials, from de-
ficiency of the drug, by Assistant Surgeons McCormick, Head, and Moses, in
three different localities. Even Peruvian bark itself failed; and Fowler's
solution, ferrocyanuret of iron, sulphate of zinc, opium, Virginia snakeroot,
and common salt, had still less success. The latter, salt, was given by Dr.

1857.]

Coolidge, Sickness and Mortality in U. S. Army.

133

Head, to 21 patients; of whom 7 recovered under its use; the average dura-
tion of these cases being 3-f days.

Very little is said, in the reports before us, of dengue. The following brief
account of it, as it prevailed at Fort Brown, Texas, in 1850, is given by
Surgeon N. S. Jarvis : —

"More than one-half of all the cases of disease reported during the quarter
were of the complaint familiarly known as the ' dengue, or break-bone fever/
"which last appellation is very characteristic of one of its prominent symptoms.
It appeared here as an epidemic in the early part of October, having previously
travelled along the line of coast from New Orleans to Galveston, Matagorda,
and Lavacca, to this place." " It continued to prevail during the whole month
of November, and a few cases have occasionally made their appearance up to
the present time. Few of the adult male population escaped an attack ;
whereas, among women and children there was a remarkable exemption. The
attack rarely' consisted of more than one paroxysm, lasting about twelve hours,
and followed by a remission or cessation of all the symptoms that marked the
approach and presence of the fever. Notwithstanding the shortness of the
paroxysm, the debility that followed was very great, and it was frequently
several weeks before the patient recovered his former strength and vigour."

In the reports from Florida, St. Augustine is alluded to, as at all times
justly esteemed' for its salubrity. It is situated upon a bay, about two miles
from the ocean, and equally sheltered from extremes of inland and marine
influence. During the winter, it is probable that no other city on the conti-
nent affords greater safety and advantage for a pulmonary invalid. It has
been, nevertheless, occasionally invaded in the autumn by yellow fever : much
more seldom, however, than the other southern cities or Key West.

In regard to the climatology of Florida, at large, some remarks are made
by Assistant Surgeon Southgate, of considerable interest, which we would
transfer at length, but for the want of space. He considers its conditions
favourable, especially to the

" Northern invalid, whose skin has been constricted during successive hard
winters, who has suffered from frequent catarrhs, and in the upper portion of
whose lung the fatal deposit has been made ; to him, a removal to Florida holds
out the prospect of greater length of days." But, on the other hand, " for those
who become consumptive in Florida, a removal to a more bracing climate is
imperatively demanded. In such, the rapid melting down of the tissues of the
lung during the warmer months, it has been my painful duty to witness in more
than a single instance. In St. Augustine, tuberculosis of the lungs is not a
rare disease. Of one family, originally numbering ten, two alone survive —
eight having been hurried to the tomb by this formidable malady. Among the
negro population it is not uncommon."

Dr. Southgate relates, in the same paper, remarkable examples of the direct
toxic effects of local miasm — as evinced in the production not only of periodic
fever, but of gastric and nervous symptoms, much intensified by particular
circumstances of exposure. " The effects," says he, " were as specific as those
produced by any poison ; and upon such evidence the mind may repose, until
the advance of science shall enable us still further to disclose the mysterious
agents by which we are surrounded." Dr. S. is reminded, forcibly, by the
facts alluded to, of the cryptogamic theory of the origin of fevers, so ingeni-
ously sustained by Prof. J. K. Mitchell.

One fact is prominently brought out, not only by Dr. Southgate, but by
several other reporters of the " army statistics :" namely, that no such thing
as acclimatization to the miasmatic influences of our southern country is to be
expected, by a non-native, after any period; but that, on the contrary, the

134

Reviews.

[July

longer his residence in such a region, the greater his liability to sickness, and the
greater its severity and his incapacity of resistance. This ought to have its
effect, certainly, in determining the time and manner of apportionment of
troops or other persons to regions which are decidedly insalubrious. Chronic
diarrhoea, of a most intractable form, is one of the frequent results of long
exposure to the climate of interior Florida j but a vivid picture is drawn by
Dr. S., of a condition not unfamiliar to the medical reader, even at the North,
as designated by the term miasmatic cachexia.

At Fort Pierce, 170 miles south of St. Augustine, the water used in drink-
ing is stated by Assistant Surgeon Conrad to be impregnated with sulphuret-
ted hydrogen. No considerable prevalence, however, of febrile diseases is
there reported. In the Rio Grande, New Mexico, Assistant Surgeon Ham-
mond has observed the same impregnation ; yet at the post where this obser-
vation was made (Socorro) intermittent fever is said to be " very rare."

A description, by Assistant Surgeon Abadie, of the worst form of southern
country fever, is so graphic, being drawn " from the life," that we think the
quotation will not be out of place, however familiar the topic. It was a
" pernicious intermittent and remittent fever," at Barrancas Barracks, Flo-
rida, in 1846.

" This disease commenced with us about the beginning of August, attacking
with little apparent violence, attended from the first with great tendency to
congestion of the different important organs, more generally the liver, alimen-
tary canal, and brain. The individual attacked appeared as if poisoned ; the
blood being changed in its character, dissolved and unnatural in appearance
when drawn, resembling the dregs of claret in water, coagulating imperfectly.
Stimulation had to be used from the commencement ; and when depletion had
to be employed, it was practised by cups, from such parts as were the most
threatened with disorganization. The treatment pursued had to be purely
eclectic, meeting the symptoms as they appeared. Powerful counter-irritation
to the surface by means of hot spt. terebinth, frictions, followed by the appli-
cation of sinapisms, so as almost to cover the whole body with them, was in-
dispensable, and was attended with signal benefit. The sheet-anchor of the
treatment was large doses of quinine and calomel to re-establish the secretory
functions, which were entirely arrested from the beginning of the attack. The
dejections from the stomach, vomiting being usually present, consisted of a
colourless, glairy fluid in some cases ; in others, dirty green or brown flocculi
were suspended in it. The discharges from the bowels presented somewhat
the same appearance, being generally watery, of a dirty black colour, the more
consistent portion of the stool being very fetid, falling to the bottom of the
vessel in a pulverulent form. During the fever the liquor ammon. acetat. with
mist, camph. and spt. nitr. dulc. was well borne and did much good. Before
the termination of the paroxysm, which was usually by the most profuse cold
sweats with very frequent and almost imperceptible pulses, quinine in ten
grain doses was given with great benefit; the pulse becoming fuller and less
frequent, the sweat more natural. The doses were repeated in intervals of
from three to five hours, arresting the paroxysm if the calomel, which had
been continued in repeated doses at the same time, had succeeded in restoring
the suspended secretions, which was manifested by the appearance of copious
bilious stools, or large dejections of a dark, tarry nature. The type of the
fever was at first intermittent, generally a double tertian, the first paroxysm
only being attended with slight rigors ; the occurrence of the paroxysm being
very irregular, mostly at night; the intermissions very short, there being none
perceptible, in some cases, for the first three days of the attack. In Septem-
ber the fever assumed the remittent type ; the septic effects of the miasmata
being more striking, the congestion less susceptible of relief. In children
under five years, in three cases out of five, the disease was ushered in by apo-
plexy or effusion on the brain, one side of the body being completely paralyzed,

1857.]

Coolidge, /Sickness and Mortality in U. S. Army.

135

whilst th.e other was thrown into spasmodic contractions. Fifty-six cases of
the disease, including a few relapses, have been treated, occurring in the fami-
lies of officers and soldiers entitled to attendance."

Fort Dallas, on the Miami River, three miles from the sea, is described by
Assistant Surgeon Adkins, as having remarkable attractions of situation ; and,
it might be inferred, of salubrity.

We must hasten over the reports from Texas, with the mention of one or
two climatic peculiarities. Rain falls every month in the year, but the great-
est quantity in the month of May. Then the rivers and creeks overflow their
banks, but subside during the month of June. The Nueces, says Assistant
Surgeon Moses, rose twenty-six feet in June, 1854. Very little rain falls
during the winter months. Yariations in temperature are often very great
and sudden ; a cold norther springing up, and freezing one who, but a few
moments before, may have been panting with heat. The heat is intense, and
nearly continuous for nine months. Even the winters are mild, except when
a norther blows. %

These northers are the striking feature of Texan climate. They often last
several days ; are frequently accompanied by rain ; are violent enough to cut
off communication between Point Isabel, the Brazos, and the shipping; and
are most common between October or November and March. The Mexicans
believe that they tend to check bilious and other fevers ; but Surgeon Moore
considers this to be a mistake.

We should suppose, from the accounts given, that Austin, on the Colorado,
was one of the most agreeable posts of this region.

In the botanical accounts of Texas, descriptions are given of the Mesquite}
a variety of acacia, peculiar to that latitude. This tree makes greater resist-
ance to the prairie fires than any other arborescent vegetation. It is abund-
ant in all parts of Texas. Its height is, on the average, from 14 to 16 feet.
It is invariably characteristic of rich land ; having under it the mesquite
grass, on which cattle fatten finely. The fruit of the tree is a slender pod,
ripe in July. Horses can subsist on this pod. The leaves of the mesquite are
bitter, slightly astringent, and tonic. The roots extend to a remarkable depth
into the earth ; sometimes 30 or 40 feet. It lives to a great age; is not
adapted to building purposes, but affords the best of firewood ; and admits of
a beautiful polish.

At Fort McKavett, Assistant Surgeon Crawford remarks upon the fact, that
in all of five cases of labor at that station, the placenta was retained from 8
to 24 hours; an occurrence which, he is informed, is not unusual in that
country. Miasmatic fevers abound in many parts of Texas ; yellow fever,
cholera, and dengue are also mentioned in the reports.

Of New Mexico, Assistant Surgeon Langworthy observes : —

"I trust I shall not incur the charge of monstrously exaggerating the facts
when I remark, that the whole territory of New Mexico is little else than a
great sterile mountainous desert, not calculated for the residence of man in a
state of civilization. There are oases, however, in all deserts ; and New Mexico
does not prove an exception to the general rule."

He adds, however, thereafter-^that

" There is no country on the face of the globe, perhaps, that surpasses New
Mexico for salubrity and purity of atmosphere, and general freedom from dis-
ease."

Assistant Surgeon Hammond states that he has never seen an indigenous
case of phthisis pulmonalis in the country. Yet his description of the popu-
lation is lamentable.

136

Reviews.

[July

" In consequence of the altitude of the country, probably ; of the impure
atmosphere in their illy-ventilated habitations ; of their inefficient clothing ;
want of cleanliness; want of exercise; scant and little varied diet; early
marriages (from 11 to 14), and an inherited cachexia, they are born with feeble
constitutions ; cut the first incisor teeth at the end of the first year of age ;
walk at two years ; are weaned at three years, or when the mother becomes
obviously enceinte ; the females menstruate at 12 and 13 ; the milk canines are
seen standing, and the permanent molares appearing at the 17th year; at 25,
they are in the ' sere and yellow leaf ;' liable to be, and suffering much when
they are, attacked by disease, they pass through life with lessened vitality, and
rarely attain to very old age. Nature has done a great deal for them. Were
they civilized and intelligent, disease would be little known among them."

In California, the hottest post in the United States is asserted by Assistant
Surgeon Wirtz to exist, at Fort Yuma, on the Colorado; latitude 32° 33' 3".
The average mean temperature for the year is 73.62°; for the summer,
89.95°, the thermometer occasionally rising to 116°, or even 124°, in the
shade.

One or two etiological anomalies occur in the endemial history of the sta-
tions in California. Thus, at Monterey, a low flat plain skirts the edge of the
town, in the centre of which is a lagoon, nearly half a mile in length, by
one-eighth in width. Within one or two miles of the town, are two other
large lagoons. During the prevalence of the high tides in the spring, the
water of the bay flows into the lagoon at the edge of the town, and keeps it
full ; but at other seasons, particularly at the latter part of the dry season,
" the waters of the lagoon recede towards the centre, leaving a good deal of
vegetable matter exposed to the sun, the odour from which is far from agree-
able when sufficiently near to inhale it." Yet Assistant Surgeon King has
" never known a case of intermittent fever originating at Monterey" although
off from the coast, to the interior as far as Salinas River, a few cases occur.
We may contrast this with Camp Far West; of which it is stated, that " al-
though there are no marshes within twenty-five miles of the post, it is con-
sidered one of the most unhealthy points in the valley of Sacramento," the
whole of which is sickly from June to October. Again, the hygienic state
of the town of Monterey, and its Californian population, is described as of
the worst kind in all respects ; so that the mortality from cholera infantum,
&c, is annually great. Yet epidemic cholera has never visited the place,
although it has prevailed in the Sacramento Yalley, at San Francisco, San
Jose, San Luis Obispo and Santa Barbara. This exemption is, of course,
unexplained.

The practice of midwifery in California, among the natives, must have
been, in 1852, in a most undeveloped state; as this example of nimia dili-
gentia shows: —

" It is the custom, in Monterey, when labour begins, to place the woman on
a chair in the middle of the room, and a rope is fastened to the rafters above
her head, which she is directed to pull. Round her abdomen, a broad towel,
or rebosa, is passed, the ends crossed behind, and intrusted to assistants, who
are instructed to tighten it when the abdominal tumour descends during the
pain, and belay there (as it were) until the arrival of the next pain, when it is
hauled taut again, so as to hold on each time to the progress made, and not
permit the usual ascent of the tumour after the subsidence of the pain. With
the same view a strong man is frequently seated behind the woman, who, with
his hands placed on her abdomen, makes strong pressure downwards, at each
pain, with the idea of assisting, by mechanical force, the contractions of the
uterus. All this time the midwife (generally some old woman) is seated in
front with one, and if possible both hands in the vagina, making all the trac-

1857.] Coolidge, Sickness and Mortality in U. JS. Army. 137

tion in her power." " These violent measures often prove fatal to both mother
and child."

The diseases peculiar to women are, naturally, most common in such a
locality.

Assistant Surgeon King asserts his belief that, in all parts of California, a
marked tendency exists to diseases of the brain. Insanity is unusually fre-
quent, to a degree not (in his opinion) accounted for by the psychical charac-
teristics of the society and circumstances of the country.

The last of the divisions reported from, in this volume, is that of Oregon
and Washington Territories. These comprise the farthest west of all the
stations on the continent.

Of Astoria, latitude 46° 11', ten miles from the Pacific, Assistant Surgeon
Moses writes : " The most noticeable feature in the climate is its equability.
The summers are cool, dry, and healthy; the winters stormy, rainy, and disa-
greeable, but mild." No endemic diseases exist, and the troops enjoy unusual
health throughout the year. Yet it is described as having no attractions as a
place of residence; the long, cheerless winter, and short, dry summer, with
a very often foggy or smoky atmosphere, rendering the days of balmy weather
few, although, when they come, delightful. The division of the year into
the two seasons, rainy and dry, is remarked by Assistant Surgeon Haden as
being about as constant there as in more southern latitudes.

At Astoria, Fort Dalles, and Fort Steilacoom, no indigenous fevers are
reported ; and their occurrence is not mentioned in any of the other reports
from Oregon and Washington Territories. We may observe, in connection
with this interesting fact, that, according to the statements of Assistant Sur-
geons Moses and Haden, no poisonous reptiles, or annoying insects, exist in
the same regions. Can the opinion of Copland be correct, that some asso-
ciation exists between the number of venomous creatures and the insalubrity
of a country ? Looking back 'to the other papers in this volume, from va-
rious regions, we may find enough to make out a plausible case in the affirm-
ative, at least as regards poisonous reptiles. In all of the numerous reports,
from all parts of the continent, when any mention is made of the existence
of venomous serpents in a locality, miasmatic fevers are also found to exist
there; with one or two partial and incomplete exceptions only. Where a
total absence of malarious fevers is mentioned, in some instances, as (besides
those of Oregon and Washington), at Forts Gaines and Eidgely, Minnesota,
allusion is made also to the absence of venomous serpents; in others, as at
Fort Conrad, New Mexico, reptiles are not named at all. The nearest ap-
proach to an exception to this coincidence is in the case of Fort Defiance,
New Mexico, where Assistant Surgeon White speaks of the existence of
" various species of lacerta and crotallus," and also asserts that " the several
cases of intermittent fever were among recruits who had been much affected
with it previously on the plains, or in the States." Near Monterey, Califor-
nia, " rattle and other snakes" are said to be found ; but, although miasmatic
fevers are said not to originate at Monterey, they occur " off from the coast,
as far interior as the Salinas River." In several of the reports, allusion is
made to the abundance of cryptoyamic plants in the miasmatic, and their
rarity in the non-malarial regions.

We had intended to abstract some of the information given in this volume
in regard to the prevalence of Cholera at the different stations; but the want
of space, and the frequency with which the subject has been under discussion
in this and other journals, may excuse the omission of details. Cholera oc-
curred at many of the posts, and in their vicinity, in 1849; less extensively

138

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[July

in 1850, 1851, 1852, and 1854. No account of cholera at any of the
U. S. forts is recorded in 1853. 1 The history of the epidemic was that of
its occurrence elsewhere ; often approximating the main routes of human
intercourse, but not exclusively, nor with regularity; scarcely ever manifest-
ing that direct coincidence with individual migration and proximity, which
alone could suggest the idea of contagion. The preference of its effective
cause for regions in which organic decomposition, especially animal, was rife,
was apparent ; in some instances, miasmatic localities seemed to be especially
marked for visitation.

On board the steamship Ohio, in July, 1852, near the Isthmus, en route
for California, cholera having prevailed, out subsiding, it appeared (in the
view of Assistant Surgeon Tripler) to be re-lighted by taking on board
61 about a dozen knapsacks that had been lying and moulding somewhere on
the Isthmus for a long time f* those men being first attacked who opened
the knapsacks for a change of clothing. The modus operandi of this would
seem to be, by the influence of putrefaction as an exciting or promotive cause.

No new symptom is mentioned in any of the cases reported, except the
occurrence, in an epidemic near Lavacca, Texas (as mentioned by Surgeon
Madison Mills, in Dec. 1848), of swelling, and sometimes paralysis of the
tongue. This symptom is said to have there occurred in " a great many
cases.7' Nor is there, in the treatment employed or proposed by the army
surgeons, any measure so novel as to require present observation.

One of the most remarkable epidemics, as to extent, recorded in the volume,
was that of Influenza, which prevailed in the summer of 1843. This is
noted in the reports from all the regions of the United States, exclusive of
Florida, Texas, California, New Mexico, Oregon, and Washington Territories.
It occurred on the coast of New England, in New York harbour, East and
West, and on the shores of the great Lakes, in the Middle Atlantic and
Middle Interior regions, and in the South Atlantic and South Interior as far
as Baton Rouge. In the whole sixteen years no epidemic of catarrh is men-
tioned besides that of 1843, except at Las Vegas, in New Mexico, in 1849.

The description of this disease, as given by Surgeon Porter, at Fort Trum-
bull, Connecticut, may interest the reader : —

" Symptoms. — General pain or soreness ; almost invariably pains of the
frontal region and loins, and frequently of the chest and epigastrium ; very
generally soreness of the globe of the eye ; pulse varying in frequency, but
almost always wanting in volume ; sometimes cough quite troublesome, and
often little or none ; skin never hot and dry, but generally inclined to be cold
and moist — amounting, in some instances, to a cold perspiration ; in many
cases thirst, in others none at all ; and in all constipation. The disease was
attended with considerable depression of the nervous power, and great derange-
ment of the liver."

In several of the more remote positions, scorbutus has repeatedly occurred,
from deficiencies of diet. Several remedies have been employed for this dis-
ease in the army, which are probably not yet equally familiar in civil prac-
tice. These are, the use of wild onions as a diet, mentioned by Assistant
Surgeon Grlisan, while west of Arkansas, in the Indian Territory ; that of
the expressed juice of the cooked leaves of the maguey, or agave Americana,
as suggested by Assistant Surgeon Perin, Texas ; the juice of the leaves of
the cactus opuntia, or prickly pear; the pJiytolacca decandra ; and the fedia

1 In the Consolidated Abstract, however, 186 cases and 94 deaths are said to have
taken place in that year.

1857.] Coolidge, Sickness and Mortality in U. S. Army. 139

radiata, or wild lamb lettuce. One writer mentions the successful adminis-
tration, in several cases, of cream of tartar in small doses, long continued.
Nitrate of potassa did not meet with general favour. Several of the reporters
speak of the agave Americana as a remedy, in the highest terms of com-
mendation. The dose of the expressed juice is from two to eight ounces,
thrice daily.

At the termination of the first part of the volume, its editor, Assistant
Surgeon Coolidge, recapitulates those deductions in regard to phthisis which
have been already cursorily alluded to. By examination of the consolidated
table given, it is found that, with the exception of West Point, the lowest
ratio of cases occurs in New Mexico, being only 1.3 per 1,000 j and the highest
in the South Atlantic Region, where it is 9.2 per 1,000. This agrees with
the previous statements of Dr. Forry, based upon similar data; with those
drawn from • statistics of the British army j and with those of Alexander
Keith Johnson,1 inferred from a still wider examination of medical geography.

The conclusions of Dr. Coolidge are the following : —

" First. That temperature, considered by itself, does not exert that marked
controlling influence upon the development or progress of phthisis which has
been attributed to it."

" Second. That the most important atmospherical condition for a consump-
tive is DRYNESS."

" Third. That next to dryness in importance is an equable temperature — a
temperature uniform for long periods, and not disturbed by sudden or frequent
changes. An uniformly low temperature is much to be preferred to an uni-
formly high temperature. The worst possible climate for a consumptive is one
with long-continued high temperature and a high dew-point."2

These are important conclusions; but no one, of course, would jump from
them to the supposition, that, in the management of phthisis, it is an error
to send patients to winter in the South. An artificial climate, obtained by
migration, so as to avoid all extremes, will afford the greatest advantage;
and we cannot suppose anything to meet this indication better than to send
the patient, or valetudinarian, to St. Augustine for the winter months, and
to Newport, R. I., for the summer.

An especial subject of inquiry, by circular, amongst the medical officers of
the army, in 1843, was that of the effects of the administration of quinine in
large doses, in intermittent, remittent, and congestive fevers. The Surgeon
General thus introduces the topic in the appendix: —

"The prominent medical feature of the Florida war was the introduction
into the army of the practice of giving quinia in large doses, during the inter-
mission of intermittent, and remission of remittent fever ; and, also, of the exhi-
bition of that remedy in the febrile stage of those diseases. Without attempting
to decide upon the originality of this practice, in any of its phases, or to determine
to whom, among the medical officers, is due the merit of introducing it into the
army (for on this point the official records are silent), it may with truth be said

1 On the Geographical Distribution of Health and Disease. Edinburgh and Lon-
don, 1856.

2 " Consumption is rare in the Arctic regions, in Siberia, Iceland, the Faroe
Islands, the Orkneys, Shetlands, and Hebrides. And, in confirmation of the opinion
that it decreases with decrease of temperature, Fuchs shows, from extensive data,
that in Northern Europe it is most prevalent at the level of the sea, and that it de-
creases with elevation to a certain point. At Marseilles, Oldenburg, and Hamburg,
near the sea-board, the mortality from this cause is about 25 per cent. ; at Eschwege,
496 feet above the sea, it is only 12 per cent. ; and at Brotterode, 1800 feet above
the sea, only 0.9 per cent." — A. K. Johnston, op. citat., p. 121.

140

Reviews.

[July

that to the medical staff of the army belongs the credit'of having demonstrated,
on an extensive scale, its safety and efficacy, and of having thereby largely con-
tributed to revolutionize the treatment of fever in this country."

The earliest reports on the subject were those of Assistant Surgeon (now
Surgeon) J. J. B. Wright, and Assistant Surgeon (now Surgeon) Chas.
McCormick, both in 1841. The remainder of those with which the Appen-
dix is occupied were given in answer to the circular of Surgeon General Law-
son ; comprising twenty-five special reports/ a selection from fifty-seven re-
turned, on the following points : 1. The extent of the experience of each. 2.
The purity and source of the medicine nsed. 3. In what doses, as regards
extreme and average quantity. 4. The diseases, and states of system in which
quinia was employed in large doses, and the corresponding effects. 5. The
inferred modus operandi; whether quinine be a tonic, a sedative, or a stimu-
lant. 6. Whether quinine has exhibited any tendency to increase the preva-
lence of diarrhoea and dysentery, or of affections of the liver and spleen ; or
whether these should all be referred to climatic influences.

There does not appear to have been entire unanimity, notwithstanding the
very general agreement, among the authors of these reports. Their experience
was ample ; the article employed was, probably, pure, being nearly all sup-
plied by the medical purveyors of the army. Neuralgia, as well as inter-
mittent, remittent, and congestive fevers, was treated with success by
quininization. But one of the reporters is decidedly opposed to the use of
large doses of quinia, never giving more than 25 grains in a single interval.
Dr. McCormick has given the maximum doses, 360 grains in 12 hours;
" with the most beneficial result." Many, however, object to its employment
during the active febrile stage, as unnecessary, at least, if not injurious ; and
Dr. McCormick himself, as well as many others, find the large doses only ne-
cessary in the severely congestive (adynamic) types of miasmatic fever, giving
but from 10 to 20 grains, in one, two, or more doses, in the intermission of
ordinary intermittent fever. The average dose in the " congestive" cases is
about 20 grains, usually given with calomel. The names " tonic," "sedative,"
"stimulant," do not seem to satisfy a majority of the writers. They state
that the action of quinia is peculiar; exhibiting, in different cases and condi-
tions, results which might be called sedative, tonic, or stimulant in turn, and
yet are accounted for by neither of these terms. In view of the objection
commonly made to the use of the word antidote (which most simply covers
the ground), perhaps the safest expression is that of Surgeon B. M. Byrne,
who designates its influence, with regard to miasmatic diseases, as that of a
powerful counter-impression; the required power of which must vary with the
intensity of the morbid cause to be counteracted j a principle of proportion
elsewhere illustrated in medicine, as in the case of opium in tetanus, emetics
in croup, &c. &c. That so powerful an agent can "do no wrong," would
seem to be incredible. Several of the writers of these reports testify that it
can, in disproportionate doses.

The best summary statement, avoiding both Scylla and Charybdis, is, per-
haps, to be found in the paper of Assistant Surgeon John Byrne; with a few
words from which we may take leave of this subject : —

" The diseases of settlers in Florida from the north assume a more inflamma-

1 From Surgeon B. F. Harney, Surg. K. S. Satterlee, Surg. R. C. Wood, Sui-g. B.
Randall, Ass. Surg. (Surgeon) J. J. B. Wright, Ass. Surg. (Surgeon) B. M. Byrne,
Ass. Surg. (Surgeon) C. McCormick, Ass. Surg. J. H. Bailey, Ass. Surg. B. C.
De Leon, Ass. Surg. T. C. Madisou, Ass. Surg. R. F. Simpson, Ass. Surg. J. Byrne.

1857.]

Coolidge, Sickness and Mortality in U. S. Army.

141

tory form during the first year of their residence in the south than they do sub-
sequently. This remark is particularly true of fevers. Hence, in fevers arising
in such subjects, due attention must be paid to the employment of antiphlogistic
measures previous to the use of quinia." Several of the reporters confirm this
statement as to the important effect of long residence in a hot and malarious
climate in relaxing the system, and lowering the type of morbid as well as
healthy action. ' This may account for some of the discrepancies in the opinions
entertained in reference to the effects of quinia/ In the middle of the paroxysm
of remittents of rather a low type, Dr. Byrne found that quinia ' did not aggra-
vate the disease, although it did not alleviate it;' and he alleges that the subsid-
ence of fever after a certain duration is so natural a phenomenon in remittent
and intermittent, that the large doses of quinia may have sometimes incorrectly
received the credit of producing the change.

" To sum up, I think that quinia should not be used in the open inflammatory
stage of any fever, no matter how long this stage may last; that it is particu-
larly efficacious in the treatment of malarious fevers only, and when some in-
termission, or pretty fair remission, can be obtained ; that it may be given in
large doses, if administered under proper circumstances, with as much impunity
as in small ones ; that it is generally a matter of no consequence in what doses
it is administered in simple intermittents and remittents, provided from ten to
twenty grains are given within a certain period of the expected paroxysm ; that
the large doses possess advantages in some few cases of remittents and inter-
mittents ; that "in congestive fevers, large doses are of great importance, and
often cannot be replaced without danger by small ones ; that quinia should be
used with a view to its anti-periodic effects and its specific influence in cases of
malarious poisoning, and not merely as a tonic, &c. ; and, finally, that if judi-
ciously used, it may be given freely and in large doses without producing dis-
ease of the abdominal viscera."

We have no space left for the consideration, at present, of the copious and
interesting Tables, of disease, mortality, meteorology, &c, which form a sort
of vertebral column to this book. They all do great credit to the industry
of the officers engaged in their elaboration ; and will afford much valuable
material for the sanitary statistician. The following is the brief summary of
Dr. Coolidge: —

" The average annual proportion of cases of disease to the numerical strength
of the army is 2.92 to 1; the corresponding ratio of deaths is 1 in 33.35, or
2.99 per cent. ; and the proportion of deaths to cases is 1 in 97, or 1.02 per
cent. Exclusive of cholera, the deaths were 1 in 38.64, or 2.58 per cent. It
is probable that even this last, is greater than the actual annual ratio of mor-
tality, as the excess of deaths in 1849 is in part attributable to diseases con-
tracted during the war."

The highest ratio of mortality, for the sixteen years, was found to be on the
southern frontier of Texas, and at the Jefferson Barracks and St. Louis
Arsenal, Missouri; the lowest, at West Point, and on the coast of New Eng-
land. The total number of deaths from disease, in the army, during the
period named, was 3,617.

Besides all that we have alluded to, this volume contains " Statistics of the
War with Mexico," and " Statistics of the Recruiting Service." These
must be passed over altogether for the present. The Surgeon-Greneral remarks,
at the close, that

" It is due to the medical staff, as a body, to state that this and other re-
ports which have emanated from the Medical Bureau, by no means fully repre-
sent the extent of their contributions to science. Within a few years past, the
medical officers have been called upon to co-operate with the Smithsonian In-
stitution, in collecting specimens of the fauna of this country, and the surgeon
general takes pleasure in being able to state that the museum of that institu-
No. LXVIL— July 1857. 10

142

Reviews.

[July

tion has been materially extended and enriched by their voluntary contribu-
tions. They have also been invited to aid Professor Ehrenberg in his work on
' Fluvial Deposits? by collecting specimens of mud and silt from the banks and
beds of rivers; and to assist Professor Agassiz in obtaining specimens of fish,
particularly from New Mexico, California, and Oregon. The responses to these
invitations have been such as to elicit the acknowledgments and. thanks of
those learned professors."

We have taken the more interest in presenting a sketch of the contents of
this valuable work, because it shows how much can be done in the collection
of medical statistics. No one will pretend to deny, that Etiology must de-
pend, for an accurate foundation, upon such definite facts as are thus collated,
upon a large scale ; nor can much less be averred of Pathology and Thera-
peutics. If we desire that our art shall really and essentially progress, it is
high time that similar results should, by the zeal of medical men, be ob-
tained, in civil practice, to those which the army medical staff has presented.
No better field for this is afforded, in the whole world, than in our own coun-
try; and the organization of the American Medical Association makes it
more than possible.

If the opportunity be, through indolence or indifference, neglected, it must
be to the detriment of our profession. If embraced, it will much enhance
its glory; and Medicine, disrobed, at last, of the cloud-like obscurity which
has surrounded her, may, hereafter, walk among her sister sciences, co-equal
with them in power, as in dignity surpassed by none. H. H.

Art. XI. — Traite Therapeutique du Quinquina et de ses Preparations. Par
P. Briquet, Medecin a THopital de La Charite, &c. &c. Deuxieme edi-
tion. Paris, 1855.

Therapeutical Treatise on Cinchona and its Preparations. By P. Briquet,
Physician of La Charite, &c. &c. Second edition. Paris, 1855.

Numerous have been the works upon the subject of Cinchona. No other
article of the materia medica has been more copiously written upon, and well
may the history of it, in its full extent, embracing all that pertains to its
natural origin and varieties, the pharmaceutical treatment of it and its appli-
cation to the cure of disease, be termed Quinology. The attention and in-
terest elicited by Cinchona from the time of its first discovery to the present
have not abated, and have arisen, from the romance which may be said to be
attached to its introduction, from the almost unique curative powers detected
in it, and, subsequently, from its furnishing the material for opening a new
chapter in organic chemistry, for which so great a debt of gratitude is due to
chemistry by practical medicine.

The mode of its discovery is still, and will, probably, be unknown. Whether
a knowledge of it was derived from the natives of South America, or is due
to the acumen of the Jesuits, whose name for so long a period it bore, has
ceased to be matter of sneculation. There is no doubt that the Jesuits intro-
duced this valuable article, and in so doing threw an apple of temporary dis-
cord into the medical world, exciting as much discussion and angry disputa-
tion as did the doctrinal tenets that at the same period convulsed the religious.
Dr. Sigmond, in his interesting lectures, has remarked that the treatises on

1857.]

Briquet, Cinchona and its Preparation'.

143

Cinchona are more numerous than could be read in a lifetime ; and Bergen,
who is the author of one of the most noted and authoritative works upon the
subject, modestly entitled "An Attempt towards a Monograph of the Barks/'
gives a list of six hundred and thirty-two authors whom he had consulted, and
of eight hundred and eight books and pamphlets which had been published,
and this did not include the whole number.

It is not our purpose to enter into a disquisition with respect to the early
litigation originating from the introduction of this valuable medicine, in which
priests and laymen, courtiers and physicians engaged with a party rancour as
virulent as it was futile. It was left for such men as Sydenham and the
English observers, Torti and his Italian school, and, finally, the author under
consideration, to calmly and dispassionately unfold its true value by analytical
observation of its effects.

It is with no fear of contradiction that we state the work of M. Briquet to
be the most complete and satisfactory that has yet appeared with respect
to the action of bark or its preparations upon the economy. His observations
have been made in the only true way, the examination of their effects upon the
different organs and general systems, and as they are modified by the circum-
stances which have a controlling influence over them, from which can be de-
duced their proper estimation and application as curative agents, and the correct
methods of exhibition. The work was presented to the Academy of Sciences
for the prize of medicine and surgery for the year 1854.

In the report of the commission of that body, consisting of the most learned
and skilful of the Parisian physicians, it is remarked that —

" The treatise of M. Briquet upon Cinchona is one of the most important
works they have had to examine ; from its extent, its precision, and, frequently,
the novelty of the researches it contains, it ought certainly to contribute to
render our knowledge more positive and more complete as well upon the phy-
siological action of this important medicine as upon its therapeutic action."

To present to the physicians of this country an exposition of M. Briquet's
results in their varied and numerous phases, the present review has been under-
taken, with the conviction that the materials afforded by his pages are of the
most interesting character, and must attract attention. It may be stated here
at the outset that it will be impossible to embrace in the review the whole
field presented in M. Briquet's treatise. All that can be accomplished will be
to give an idea of the extent of his labours, and a full account of the physiolo-
gical results arrived at by him; the portion most interesting at the present
time from its novelty and completeness.

The introduction is devoted to a general survey of the natural history and
commercial details of bark, as well as to a condensed account of its introduc-
tion. In this there is nothing that cannot be found in the comprehensive
works which treat of the subject. The same information may be derived from
the U. S. Dispensatory or Pereira's Materia Medica. The medical part of
the introduction consists of a sketch of the opinions entertained of it as a
therapeutic agent, from the time of its discovery, of the authorities through
whose instrumentality it has advanced in public estimation, and the reasons
which led the author to enter upon this field of exploration. Upon these it
is not necessary to dwell at present, as the matter presented will be inter-
woven with the subsequent details of M. Briquet's researches.

In the language of the author the

" Work includes two kinds of researches, the one purely experimental, which
have as their aim the study of the direct effects of Cinchona in large doses upon
sound animals ; the other deductions from pathological conditions attendant

144

Reviews.

[July

upon six hundred subjects affected with rheumatism, typhoid fever, intermittent
fever, or other diseases treated by sulphate of quinine in different doses/'

And further he remarks, the analysis of the particular phenomena which
are produced during the administration of these large doses leads to the pre-
cise determination of the nature of the power of bark, and also gives the key
to the mode of action of this substance in diseases for which it is generally
given in small doses; and, finally, presents the only exact means of determin-
ing the value of the diverse medicinal forms under which it is exhibited, and
the force of absorption from the various surfaces of the body.

The first part contains researches upon the action of the several principles
of cinchona upon the principal organs and systems, and upon the fluids of the
body.

The second part comprises, 1, all that has relation to the absorption of these
substances, and their elimination from the economy ; 2, the examination of
the different circumstances which can influence this double operation ; 3, the
study of the diverse influences susceptible of changing the action in the organs
of the portion of these substances which may be absorbed.

The third part is devoted to the therapeutic application of the article and
its preparations.

The fourth part is occupied with the pharmaceutic treatment, the value of
the preparations, the doses, the forms best adapted for penetration into the eco-
nomy, and the surfaces best adapted to this purpose.

Part First. Study of the action of cinchona upon the different organ-
isms of the animal economy. — Different views have been entertained with
respect to the mode in which bark produces its effects, taking their complexion
from the preconceived ideas of their promulgators, or the peculiar physiological
tenets which held sway for the time. The first attempt to determine the
modus operandi was made by Torti, in 1700, and was directed to the duode-
num, where the febrile principle was supposed to reside. The fluids of the
stomach and duodenum were submitted to the action of decoction of bark.
Friend, in 1775, experimented in the same way upon the blood; and Hales
conceiving that the styptic property was the medicinal one, studied it with
reference to this impression. Pringle and Mackbride recognized in it an
antiseptic property. All of these depended upon the chemical reaction which
the ingredients of cinchona were capable of producing either with the secre-
tions, the blood, or the tissues in a live or dead condition, and hinged princi-
pally upon the presence of tannin. Upon the discovery of the alkaloids,
Magendie led the way in a more profitable experimentation by injecting the
sulphate of quinia into the vessels of animals. He came to the conclusion it
was innocuous; his quantities were not very great, however, and his experi-
ments have been regarded as too general. At this epoch the doctrines of
Brouss,ais were in full sway, by whom bark and its preparations were regarded
as stimulants, and the sulphate of quinia as incendiary. In this light Duval
and Beraudi regarded the article. Long after, and in accordance with the
prevalent medical ideas of Italy, Professor Giacomini of Padua published a
series of experiments which he had instituted for the purpose of proving the
hyposthenic properties of the sulphate of quinia, but the results were invali-
dated by the manner of performing the experiments, the exhibition of the
salt being followed by alcohol or prussic acid to antagonize its action or aid in
it. From these experiments only one thing is proved, that the salt mentioned
is possessed of toxicological properties, and we have given to the medical
world the first intimation of the cerebro-nervous effects, now fully recognized.
Lately, Dr. Melier, under the impression that the toxicological properties of

1857.]

Briquet, Cinchona and its Preparations.

145

the salts of quinia had not been sufficiently studied in the work of Griacomini,
and instigated further by the application made of these articles in the treat-
ment of different acute diseases, undertook, after the method of Magendie, to
experiment upon dogs, and found that agitation of the frame, dilatation of the
pupils, gradual weakness, and sometimes convulsive movements were the
result. Upon examination, the blood appeared liquefied or the serum sangui-
nolent, and badly separating from the coagulum, with deep congestion of the
lungs and mucous membrane. This series of experiments proved nothing
more than those of Griacomini, with the exception of the liquefaction of the
blood. In the pathological results the only difference consists in the state of
the mucous membrane of the alimentary canal; by the Italian experimenter
this portion of the body is represented as normal \ by the Frenchman, as deeply
congested. The probability is the theoretical views of each influenced their
mode of conclusion, the first being a contra-stimulist and the latter a Brous-
saisist. Still later, M. Monneret published the results of some experiments to
determine how far the sulphate of quinia could be borne without danger, and
came to the conclusion that Dr. Melier had exaggerated the danger arising
from large doses. This was the state of our knowledge of the action of the
salts of cinchona, when, first in 1842, M. Briquet commenced his researches.

Action on the Circulation. — It is known that cinchona has always been
regarded as possessing the property of augmenting the energy of the heart, of
increasing the force of the pulse and its frequency, and of rendering the blood
more plastic. This is the result of the administration of the bark itself or its
alkaloids in very moderate doses. It is a physiological mode of operation.
But if, in place of small, it is administered in large doses, and especially if
the alkaloids are given, things are changed, and if attentively observed, three
notable modifications are presented in the circulation, the first bearing upon
the frequency of the pulse, the second upon its force, and the third upon the
blood itself. The salt to which the first attention is given is of

Quinia. — From this alkaloid or its salts the preceding results are habitually
induced.

Modification in the frequency of the pulse. — The effect of reducing the
pulse in frequency has been noticed by many practical men when the sulphate
of quinia was given. It was a result known to and reported by G-iacomini,
Guersant, Favier, Bailly and Banquier, Silvy, Lembert, and others. M.
Briquet reports the result of his .observations. The first cases reported by
him were labouring under chronic rheumatism; 19 of these cases were
treated with from 3 to 5 grammes1 of the salt per diem. Of these, 13 evinced
a decided reduction of the pulse, varying from 5 to 25 beats per minute, as
follows : —

In 5 cases a reduction
2 " "

1 case "

2 «« it

2 " <<

2 << «<
2 << ««

In the 6 remaining cases 2 presented a more elevated state of the pulse,
and 4 little or no change of it.

The next series of cases were those of acute articular rheumatism; 20 cases

1 The gramme contains 15.4340 grains. For the conversion of French weights
into the English standard, we would refer to the table in the U. S. Dispensatory.

of 5 beats.

7 "

10 "

13 "

14 "

15 "
21 "
25 "

146

Reviews.

[July

of the disease were treated with 5 or 6 grammes per diem. Of which, the
average pulse in 6 was above 100; in 11, 90; and in 3, 60 per minute.

At the end of the first day the average reduction was 18 J. Two thirds of
the cases manifested this reduction, and one-third no change. At the end of
the second day the reduction averaged 22 per minute. The diminution occurred
in 19 cases. The average standard of the pulse was 70 At the end of the
third day, the average reduction was 26. On the fourth day, average reduc-
tion 28, average of the pulse 62. In none of the cases was there exaltation
of frequency.

Of those whose pulse was from 60 to 69, the average reduction was 12 ; from
70 to 99 it was above 24, and above 100 it was 42. Upon going out of the
hospital the cases presented a pulse of 65, which gave a difference of 25 pul-
sations in the minute from the initial pulse.

Nine cases were treated with 4 grammes of the sulphate of quinia daily.
The mean pulse of these was 85 §, a third of the cases having the pulse above
100, and one case at 60. After the first day the mean diminution of the
pulse was 14 1. In no case was there an increase, and three-fourths were
impressed by the medicine. After the second day the diminution was 22.
No augmentation, and seven-eighths were impressed. On the third day the
diminution was 24 pulsations. Augmentation occurred in one. On the
fourth day the diminution was 21, and the average pulse was 66. Of these
nine cases, the one with 60 pulsations at the commencement underwent an
increase of 5. In those from 70 to 90 pulsations per minute there was a
decrease of 15, and in those of 100 and upwards 42 pulsations. On leaving
the hospital the average pulse was 62 \y giving a difference from the initial
pulse of 25.

Twenty-eight cases were treated with 3 grammes of sulphate of quinia daily.
The mean pulse was 80. One case presented the pulse 60. A fourth part
had the pulse above 100. After the first day the mean diminution of the
pulse was 10. In 4 cases there was an augmentation of the pulse; in f there
was diminution. On the second day mean diminution of the pulse was 15.
In only two was there augmentation in frequency. In | there was diminu-
tion ; mean pulse, 73. Third day diminution 20 ; still augmentation in 2
cases. Fourth day diminution 22 J ; augmentation in 3 cases, and a diminu-
tion in -| of the cases; mean pulse, 66g. Of these 28 cases there was a
reduction of 3 in those having the initial pulse from 60 to 69; of 19 in those
from 70 to 99 ; and of 40 in those from 100 and upwards. The mean pulse
upon going out was 60 J, giving a difference of 28 pulsations from the initial
pulse.

Forty-five cases were treated with 20 to 25 decigrammes of sulphate of
quinia; mean pulse, 91; T\ of the cases had a pulse of 60; \ had it 100
and above. After the first day the mean reduction was 11; 4 had an aug-
mentation; | had diminution. Second day mean diminution, 14; 2 cases
had pulse augmented. In f- there was reduction ; mean pulse, 73. Third
day, mean diminution 17; augmentation in 2, and diminution in Fourth
day, mean diminution 19 ; augmentation, 1 ; mean pulse, 64. Of these 45
cases the diminution was 5 in those whose initial pulse was 60 to 69, 18 in
those from 70 to 99, and 34 in those of 100 and upwards.

Twenty-nine cases were treated with from 10 to 15 decigrammes daily;
mean initial pulse, 91 £ ; ± had the pulse 60, and } had it 100 and upwards.
After the first day mean diminution, 14 ; augmentation in 1, and diminution
in -§-. Second day, mean diminution 17; augmentation in frequency in 2, and
a diminution in £ ; mean pulse, 76£. Third day, mean diminution, 23 ;

1857.]

Briquet, Cinchona and its Preparations.

147

augmentation in 2; diminution in Fourth day, mean diminution, 25;
augmentation in 3 cases ; diminution in | ; mean pulse 70. Of these cases
there was a reduction of 2 per minute in those having the pulse from 60 to
69, 24 in those from 70 to 99, and 38 in those of 100 and upwards. Upon
leaving, the mean pulse was 68, giving a difference of 23 on the initial pulse.

Similar results were arrived at when the patients were treated with the
sulphate of quinia in combination with the acetate of morphia, and when the
sulphate of quinia was exhibited after sanguine evacuations.

Without reference to the impression upon the disease, but simply to that
upon the pulse, M. Briquet thus sums up the facts presented to him : —

"Of one hundred and seventy-one patients of every age, sex, and condition
attacked with articular inflammatory rheumatism of diverse intensity, and
treated before their entrance into the hospital by different methods, medica-
tion by sulphate of quinia, in large doses, produced diminution in the fre-
quency of the pulse in 120 cases on the first day of treatment; in 144 on the
second day, and in 155 on the third day. This reduction was from 7 to 18 pul-
sations for thej^rs^; 12 to 22 for the second, and 13 to 26 for the third day. It
was as much more, considerable, as the dose was large. Thus, with doses of 5
grammes there was on the third day a mean reduction of 25 pulsations; with
4 grammes, of 24 ; with 3 grammes, of 20; with 2 grammes, of 17, and with 1
gramme, of 4 pulsations. Finally, the reduction has been, other things being
equal, constantly proportional to the antecedent frequency of the pulse."

The latter is evident from the inspection of the foregoing specifications
which have been given.

Effect upon the pulse in typhoid fever. — The patients treated at the Hos-
pital Cochin, in 1842, by MM. Blache and Briquet, were 42 in number.
They found, 1st, that the pulse underwent a reduction in | of the cases; 2dly,
that in 4 light cases, treated by 2 grammes per diem, the pulse, which was
100 before the employment of the medicine, fell to 80; 3dly, that in 19
cases, where the disease of the gravest type was treated with doses of from 2
to 4 grammes, the pulse, having been before the exhibition at a mean of 96,
to the extremes of 120 to 85, fell in 18 of them, after two days, to 78, with
extremes of 96 to 60, and at the end of 5 or 6 days to 65 pulsations in half
the cases, and to 75 in the other half; 4thly, that in 11 cases of great seve-
rity, treated with 3 and 4 grammes daily, the mean pulse before the treatment
being 98, with the extremes of 125 to 68, fell, at the end of 2 days, to 75,
with the extremes of 90 to 60; and 5thly, that in 8 patients who died, the
average pulse being 104, fell the next day after the administration of 3 to 5
grammes to 82, and the third and fourth days to 71^. It resumed more
slowly its frequency in proportion as the fatal termination was near.

It is seen from these results, that in typhoid fever, as in rheumatism, the
diminution of the number of the pulsations has always been as much more
considerable as the pulse was antecedently more frequent. There is a, differ-
ence, however, observable between the two diseases. In both of the affec-
tions the circulation does not remain in the same way under the influence of
the medicine through the whole course of the affection. In the greater num-
ber of rheumatic patients, the depressive influence is continued to the same
degree during the continuance of the malady, rheumatism yielding much
better to the sulphate of quinia. In the cases of typhoid fever, on the con-
trary, the pulse, at the end of some days, often reassumed by degrees its fre-
quency, either when the disease became worse, or inflammation set in from
the course of the affection or from local excitant action of the salt.

It frequently happened that the influence upon the circulation persisted
many days after the suspension of the medicine, and in several cases patients

148

Reviews.

[July

left the hospital with the pulse below the natural standard. As a general
rule, however, the pulse was more rapid after convalescence than during the
disease, and under the influence of the remedy.

M. Briquet argues that so constant an effect upon the circulation cannot be
a fortuitous circumstance; it is absolutely necessary to admit that it is the
result of medication; it is produced immediately by it; it ceases with it, and
is found in its variations always in direct relation with the medicine. That
the effect upon the circulation is owing to the influence over the disease M.
Briquet is unwilling to admit, as the direct impression is too soon, and, more-
over, the influence is perceived where it exercises little or no control over the
disease, and this he shows by a resume of his cases.

Modification of the force of the pulse. — The weakening of the pulse was
noticed for the first time by Giacomini in a case where, by mistake, 12
grammes of the sulphate of quinia were taken at once. There were induced
a dangerous state of syncope, and almost entire absence of pulse in the radial
arteries, coldness of the skin, slowness of respiration, extreme feebleness of
the voice, and imminent threatening of dissolution. Legroux also observed
this extreme reduction. Briquet informs us that he has equally observed it,
both in rheumatism and typhoid fever, and regards it as one of the effects
the least doubtful of sulphate of quinia. The diminution of force, as that of
frequency, is proportioned to the dose. This fact was further verified by
experiment upon animals conducted with the Hemodynamometer of Poisseuille.
The experiments are most interesting and ingenious. Our space forbids re-
porting them.

Action of the salts of quinia on the blood. — There is, at present, no
doubt of the introduction of a quinia salt, or in fact of any of the salts of
the cinchona alkaloids, into the circulation. It has been proved by the
researches of Messieurs Henry, Lannaux, and Follin, as well as others.
The question then arises, what effect is produced upon the blood itself?
Friend, who first experimented upon this subject, upon the blood when drawn
and subjected to the action of a decoction of bark, thought it became more
fluid ; a fact in opposition to experience with solutions containing tannic acid.
Melier came to a like conclusion, as also Monneret and Legroux, with the
sulphate of quinia.

M. Briquet, to determine the effect of the sulphate upon blood drawn from
the body, performed similar experiments, and found that the effect was not
absolute, but varied according to the quantity of the salt; thus, when 1
gramme of the bisulphate (neutral sulphate) was dissolved in 30 grammes of
water and placed in contact with the same amount of recently drawn blood, it
became at the end of 24 hours completely liquid. Examined by Mr. Donne
under the microscope, the globules were found to be destroyed. With 25 milli-
grammes no effect was observable; 10 centigrammes rendered the clot soft.
From the large quantity required to liquefy the blood out of the body, no in-
ference can be drawn with respect to its effects in the system, and this point M.
Briquet endeavours to elucidate. He experimented with six dogs, into whose
jugular veins from 15 decigrammes to 2 grammes of the bisulphate of quinia
were injected; the animals died soon after the injection. The blood decidedly
coagulated, and the heart was filled with a hard black clot on the right side,
and a scarlet one on the left. The same tendency to coagulation occurred in
other experiments for different purposes, when the salt was taken by the sto-
mach. But to determine the question by direct analysis he proceeded to
determine the amount of the elements of the blood, before and after the
administration of the medicine, and found, 1st, that always the amount of

1857.]

Briquet, Cinchona and its Preparations.

149

fibrin increased after the introduction of the salt, and diminished when it was
suspended ; 2dly, that the globules diminished, a fact which he does not alto-
gether attribute to the sulphate of quinia; 3dly, that always the quantity of
water increased; and 4thly, that the amount of salts and fibrin was so little
affected that the effect upon them may be said to be none.

The experiments upon the blood of dogs were conducted most carefully
and upon a plan somewhat different from that of Andral and Gravarret. We
present the results for the second experiment as an illustration of the results
above stated: —

Before the action of salt. After the action. Difference.

Dry fibrin . . 0 gr. 34 0 gr. 82 More than double.

Globules ... 16 " 80 11 " 71 I less.

Salts and albumen 8 " 42 7 " 27 £ less.

Water . ... 74 " 44 80 " 90 *** more.

100.00 100.00

But M. Briquet does not rest his views solely on his experiments upon
animals, he appeals to his clinical observation. Thus in all cases he states,
where he bled rheumatic patients treated by sulphate of quinia he found the
blood well coagulated and covered by a thick buffy coat. With respect to
the diminution of the red corpuscles he informs us that he has seen rheu-
matic patients treated by this remedy in doses of 3 to 4 grammes, in whom,
besides titubation and collapse, there were evinced a waxy colour of the skin,
paleness of the lips and gums, and coldness of the surface, which anaemic
state was easily dissipated. In two cases treated with the quantity above
mentioned he saw infiltration of the limbs and serous effusion into the thorax
and abdomen, the serous diathesis, as he terms it, was, however, speedily re-
moved; and finally in some cases treated in the same way a light hydrsomic
murmur presented itself. With reference to these experiments and observa-
tions he thus sums up : —

"Observation and experiment unite in demonstrating that sulphate of quinia
does not liquefy directly the blood, but on the contrary the quantity of fibrin in
it is notably augmented, and consequently all the inductions which have been
drawn from a pretended liquefaction fall of themselves. As to the diminution
of the number of globules and the augmentation of the proportion of serum,
investigation does not afford anything sufficiently positive to establish between
them and the sulphate of quinia a determinate relation."

Where a liquefaction of the blood is produced he attributes it to the poi-
sonous action upon the organs, and the consequent organic and functional
effects upon them affecting the fluids. We have given M. Briquet's results
and statements as they are presented to us in his treatise. With respect to
the pathological observations, how far they originated in the nature of the
malady, rheumatism, with which they were connected, we leave to the expe-
rience of our readers.

Cinchonia. — It is not necessary to enter upon the proof of the effects of
this alkaloid, as has been done with respect to quinia. It is sufficient to state
that the results exhibited a like effect upon the action of the heart, but to a
less degree. M. Briquet thinks that it is one-third less powerful.

Quinidia. — M. Briquet, from his experience, is of opinion that the impres-
sion of this base is nearly equal to that of quinia.

The extracts are only energetic in proportion to the amount of active prin-
ciples that they contain.

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[J^y

Causes of the influence of the alkaloids of cinchona upon the circulation.
— From experiments instituted to determine these, and which were conducted
first by injecting the sulphate of quinia into the circulation of the brain
from the carotid, and into that of the heart from the aorta and coronary
vessels, M. Briquet came to the conclusion that the effect of the salt upon
the circulation was not produced through the intervention of the brain, but
that it had a direct action upon the heart itself. When injected into the
general arterial circulation — the stomach, and the cellular tissue — these results
were the same, only modified by the slowness of the impression upon the
organ.

As a direct consequence of the depressing impression upon the heart is the
production of a congested state of the blood in the venous system. In. sup-
port of this M. Briquet states that he constantly found in animals killed by
the sulphate of quinia considerable injection of the pia mater, distension of
the large veins of the heart as well as of the lungs and mesentery, in which
observations he is sustained by Griacomini and Melier. This distension was
observed not only in those animals who survived the experiment several days,
but in those who immediately succumbed to it. The buzzing in the ears,
giddiness, and quinine intoxication, are attributed to the same condition.
What occurs in the vessels of the brain occurs also in those of other organs,
only that as distension of their vessels produces no appreciable disturbance,
it is not perceived but upon autopsy. M. Briquet is led to suppose that the
congestion is less in the capillaries than in the larger vessels, and that dis-
tension of the venous system of the brain may more easily occur than else-
where.

From the power which bark or its alkaloids possess of depressing the cir-
culation, its anti-inflammatory influence becomes conspicuous, and he attributes
what is termed the tonic property to the other ingredients in bark, when this
is used, or to the feeble doses of its alkaline salts. *

To sum up the results of the observations which have been made by our
author with reference to the depression of the circulation, the following propo-
sitions may be stated as we find them in his work, and it may be premised
that they are derived from the study of three hundred cases.

1st. That the maximum of diminution in the frequency of the pulse rarely
goes beyond 20 to 25 pulsations per minute in the 24 hours.

2dly. That the diminution of the frequency of the pulse is always in direct
ratio to the previous acceleration.

3. That in no case is the pulse depressed below 40 pulsations per minute.

4. That the co-existence of a large proportion of fibrin in the blood, or
of a sufficiently intense inflammation, exercises an influence upon the heart
which the sedative influence of quinia exhibited in doses within the bounds
of prudence cannot neutralize.

5. That the administration of the salts of quinia, in doses sufficient to
produce a sedative impression upon the circulation, produces in the economy
so serious a perturbation, that the risk ought not to be run, except when the
disease is serious either from its duration, its gravity, or the accidents and
danger to which it may expose the patient.

The idea of bark or its preparations producing an affection simulative of
intermittent fever is discussed and denied in toto By our author. With respect
to this point he authoritatively states —

" Although I have much employed the sulphate of quinia, and in large doses,
I have never observed quinine-intermittent fever, nor anything which resem-

1857.]

Briquet, Cinchona and its Preparations.

151

bles it. I have never recognized anything but the production of the phenomena
of reaction developed under the influence of the excitant action."

Action upon the brain and its appendages. — After alluding to the notice
which had been taken of the action of bark upon the brain, and especially of
the impression of the sulphate of quinia after its discovery, M. Briquet pro-
ceeds to the exposition of his own experimental and observed results. The
experiments were conducted by injecting the salt directly into the circulation
of the brain through the carotid, by introducing it into the jugular vein, crural
artery, pleura, and cellular tissue, or into the stomach. From which the
following conclusions have been drawn by him : —

1. That the salts of cinchona have a direct and immediate action upon the
encephalo-rachidian structure, the functions of which they pervert, weaken, or
destroy.

2. That this action is divided into two periods, one during which there is
perversion and excitation, the other during which sedation is manifested.

3. That the first period is as much more decided as these salts are intro-
duced rapidly, directly, and in quantity into the brain, but its duration is
proportionably short.

4. That the second period, which is sought for by medication in large doses,
generally preponderates, but that it comes on much more quickly and lasts a
much longer time when the salts are introduced indirectly and slowly, mole-
cule by molecule, into the encephalon.

5. That this action is purely dynamical, and does not excite phlogosis but
in rare cases, where the action has been too energetic or too direct.

Where death occurred in these experiments there was more or less deep
injection of the pia mater, and inflammation of the membranes or substance
of the brain. This latter was rare.

From the experiments upon animals let us now pass to the report of his
therapeutical observations, from which it appears that patients who take from
25 to 30 centigrammes of sulphate of quinia at a time, or a gramme in divided
doses in the twelve hours, usually suffer weight and derangement of the head,
sometimes headache, often buzzing in the ears, vertigo, and light titubation.
If the quantity of the salt is larger, or the doses nearer each other, these
troubles are much more decided, are accompanied with a feeling of fulness,
tension, and throbbing of the head, with redness and flushes of heat in the
face, excitement of the eye, epistaxis, agitation, inquietude, and jerking of the
extremities, phenomena indicating excitation of the brain. These derange-
ments are often little marked, having a duration of some hours, after which
moderate feebleness and somnolence, slight torpor and prostration are ex-
hibited.

If the quantity of the sulphate of quinia is carried to two grammes and
upwards, given continuously during several days, instead of light sedation, there
are observed oppression and very decided sinking, stupor, much titubation,
deafness, dimness of sight, dilatation of the pupils, obtuse sensibility, great
weakness of muscular power, and trembling, phenomena which denote nota-
ble diminution in the general sensibility and contractility of the muscles.

And, finally, if the dose of the sulphate is too great, these accidents end in
complete loss of consciousness, absolute loss of sight and hearing, insensibility
and immobility. After the above general exposition of the effects produced
by the salts of bark, M. Briquet proceeds to comment upon the most important
of them, and, as his remarks are interesting, we shall follow him in presenting
upon each effect such as are important.

Headache. — This symptom is not regarded of moment. In three hundred

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subjects treated by sulphate of quinia it did not acquire the least gravity. In
typhoid fever the headache was rather allayed by the medicine.

Trouble of audition. — The buzzing, when intense, is accompanied with dif-
ficulty of hearing. Deafness, however, is infrequent, and he has seen it only
twice. The buzzing appears to come on soon, and to last in proportion to the
quantity taken. Deafness, from his own observation and that of others, passes
off with the other symptoms, but still it has been lasting for a length of time
in certain cases, and has even been permanent. He attributes this latter
symptom to paralysis of the auditory nerve.

Trouble of vision. — This is less common than the preceding. It is accom-
panied with dilatation of the pupil, and difficulty of seeing objects, often
double. He has seen four cases of incomplete amaurosis following very large
doses continued, in one case lasting a month. This symptom may be accom-
panied by all the worst effects upon the brain, or only by deafness coming on
rapidly or slowly. In no case has amaurosis been complete or incurable. It
is attributable to a paralysis of the optic nerve.

Vertigo and titubation. — These are among the most common effects of
sulphate of quinia. They are for the most part incident to the effort to rise,
which causes a kind of syncope, with its concomitants. They are remedied by
the horizontal position, but may last several days after the withdrawal of the
medicine. Titubation is less frequent than vertigo, and is caused by large
doses, usually 2 grammes per diem. It accompanies the very decided effects
upon the brain. It is dissipated with ease, and lasts but a day or two after
the remedy is suspended. He considers it owing to nervous prostration, and
resembling a similar condition in typhoid fever. M. Monneret has given it
the name of tj/phic state. It may be accompanied by epistaxis. In the pre-
sence of titubation, M. Briquet counsels the suspension of the medicine.

Delirium. — This is rarely observed, and only when the subjects are endowed
with excessive nervous susceptibility in feverish conditions or plethora, and
when the medicine is given too rapidly. In two hundred cases treated for
rheumatism he has seen it six times. Trousseau and Husson each report a
case where it occurred. Monneret, Legroux, and Yigla have also seen it.
The name quinine intoxication has been given to this condition, which assumes
different forms, following the course of that from alcohol. M. Briquet is of
opinion that this delirium no more depends upon meningitis than ordinary
intoxication. It comes on slowly and lasts usually but a few hours. It is
dependent on congestion. The treatment of it is suspension of the medicine
and the usual course.

Meningitis. — This inflammation is one of the gravest accidents that can be
attributed to the sulphate of quinia, if the facts reported were as conclusive as
has been supposed. M. Briquet, however, assures us that in his whole expe-
rience he has not met with a case that could be attributed to the remedy, and
by an analysis of the cases, few in number, which have been reported, as well
as by exhibiting that meningitis is an attendant upon rheumatic attacks,
the disease in connection with which that complication presented itself after
large doses of sulphate of quinia, has brought a strong argument to bear against
the supposition that it was the result of treatment. Yet he does not deny the
possibility of meningitis being produced by the salt. In this respect it resem-
bles alcohol, which, with a tendency to disturb in a similar way the actions of
the brain, rarely induces the affection alluded to.

Convulsions. — The occurrence of these, one of the gravest results of de-
rangement of the brain, is rare. They may result in experiments upon
animals when the sulphate of quinia is introduced too suddenly, or in too

1857.] Briquet, Cinchona and its Preparations. 153

great quantity. Although cases of the production of convulsions are on
record, M. Briquet informs us that neither he nor his colleague, M. Blache,
has ever seen the least approach to them in the patients treated for typhoid
fever or rheumatism, and yet the sulphate of quinia has been carried to from
3 to 6 grammes in the 24 hours in the former disease. He thinks that when
occurring it is from the mal-administration of the medicine, giving too much
at a time and not dividing the doses.

General collapse. — When experimenting upon animals, collapse was fre-
quently brought on, and the phenomena pertaining to it have presented them-
selves in man, the result of the depressing power, already dilated upon, car-
ried to an extreme extent. Such results have been reported by Griacomini
and Guersant, but excessive doses were taken, in one case 12 grammes and in
others over 16 grammes. The symptoms were extreme weakness and pros-
tration, immobility, coma and loss of consciousness, insensibility of the skin,
of sight, hearing, dilatation and immobility of the pupils, livid appearance of
the face, laboured respiration, sinking of the pulse and coldness of surface.
The effects, in fact, of narcotics. One of the cases proved fatal, but the author
has not met with such cases, although with the 2 and 3 grammes daily, the
sedative effects were fully developed.

Paralysis. — This he has never seen, either in his experiments, or in the
treatment of his patients.

The action of sulphate of quinia upon the spinal marrow is, in his view,
the same as upon the brain. With respect to cinchonia and its salts the mode
of operation is similar to that of the more potent principle and its salts, vary-
ing only in degree, and the same may be said of quinidia and quiuoidine.

Effects upon the lungs. — The respiratory apparatus is one of those upon
which cinchona in large doses exercises the least influence ; the symptoms
may be taken separately.

Prsecordial uneasiness. — This sometimes is marked and agonizing, with alter-
ation of the features and colour. It is usual in the weak or nervous. M.
Briquet regards the symptom as an indication to stop the medicine or dimi-
nish the dose.

Dyspnoea. — This he has seen twice, the paroxysms resembled the effect of
cutting the pneumogastric nerve, and appeared to be an effect of sedative
action on these nerves.

Engorgement of the lungs. — With respect to this the author asserts that
"the greater number of experiments and all observations in disease agree in
establishing the fact that the sulphate of quinine does not produce directly
either active or passive congestion of the lungs/'

Action on the alimentary canal. — The mouth is usually little affected by
the use of sulphate of quinia, and he has rarely seen the mucous membrane
inflamed, yet the continued exhibition in large doses may lead to diphtheritis.
The tongue presents habitually at the end of a few days, from the use of 2 or
3 grammes daily, a whitish, tenacious coating, which slowly passes off ; rarely
does the surface become red and dry. When 1 or 2 grammes are given daily,
it undergoes usually no modification. Even in typhoid fever the dryness of
the tongue and fuliginosities are not augmented. The reverse may even take
place, and the tongue improve. The pharynx is rarely irritated ; this occurred
but twice under his observation.

The stomach is affected by the salt differently, according to the state of the
system, whether presenting no fever or feverish, according to the condition
of the organ whether healthy or irritated. In the non-feverish condition it
acts as a stimulant and tonic. When the stomach is irritable, nausea and

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[July

vomiting may occur. In the ordinary doses the sulphate of quinia is tole-
rated by the stomach, but if incautiously given it may provoke inflammation,
or if inflammation exist it may be increased.

Upon the intestines very much the same effects may be induced, and the
same circumstance maybe regarded as modifying the action. Purgation may
be induced from the irritant impression. In their impression upon both the last
mentioned organs the sulphate of cinchonia and the salts of this base are less
active. Quinoidine and quinidia resemble quinia. The preparations of bark
are likely to be astringent.

Action upon the spleen and liver. — With respect to the first mentioned
organ, contrary to the assertion of Piorry that a direct and immediate con-
tractile influence is exerted upon it, M. Briquet informs us " that he has
treated a certain number of fever patients labouring under enlargement of the
spleen, with a solution of 1 gramme of sulphate of quinia in alcohol, and in
none of the cases has he seen in eight or ten minutes (as claimed for the
remedy) the slightest change of volume yet these tumefactions were resolv-
ed subsequently by the prolonged use of it.

With respect to the liver, although from the routes of absorption this or-
gan is necessarily reached by the salt, and it has been detected there supera-
bundantly by Lannaux and Follin, yet we know nothing of any peculiar
effect it is capable of producing.

Action upon the urinary and genital organs. — As the kidneys constitute
an emunctory for its elimination, and the sulphate of quinia is a local stimu-
lant, it may be anticipated that a diuretic effect can be produced. Inordi-
nately it may produce the effect of stimulating diuretics, cases of which are
on record, in the form of inflammation of the bladder or haematuria, or
strangury. The idea that it has an effect upon the uterus has attracted at-
tention to it as an emmenagogue. M. Briquet states that upon the latter
organ he has observed no marked influence.

The local action of the sulphate of quinia upon the skin is irritant, and
hence the suffering which sometimes attends its application endermically.
Upon the sound skin some irritation may be produced. Connected with the
internal exhibition, where there is a lowering of the circulation there is re-
duction of the temperature of the skin.

With this exposition of the action of the sulphate of quinia and the salts
of bark upon the several organs of the body terminates the first part of the
treatise. Our limits do not permit us to present the admirable " showing
up" of Homoeopathy with which the author treats us in the conclusion of
this part, but if ever the absurdity and folly of Hahnemann were exhibited
to the world, they have been to their full extent by M. Briquet.

Part second is devoted to the mode of absorption and elimination of the salts
of cinchona.

M. Briquet infers that there is no change or decomposition of the alkaloids
in the stomach, but that they are immediately absorbed and taken into the
circulation without the action of the stomach upon them, or in other words
undergoing changes from digestion. The salts of the alkaloids, however, may
be subject to the same reactions as exterior to the body, but the alkaloids are
left for easy or impeded absorption according to circumstances. As in the
uncombined state the solution of them is limited, when combined with acids
the salts formed are introduced in proportion to their solubility. The rapidity
is marked by the impression on the sensorium. The presence of quinia in
the blood has been determined by Lannaux and Follin as well as by M. 0.
Henry and Fordos.

1857.]

Briquet, Cinchona and its Preparations.

155

In opposition to the opinion of M. Mialhe, that the salts of the alkaloids
are decomposed in the blood and the bases uniting with the albumen thicken
that fluid, our author presents the following experiments which were made by
himself and M. Quevenne.

1. A filtered saturation of sulphate of quinia was mixed with serum, just
in equal amount, and then with a third part of that liquid at the tempera-
ture of 20 C In neither of the mixtures was there any deposit in 24 hours.

2. 5 centigrammes of neutral sulphate of quinia were placed in contact
with 20 grammes of pure water, and with a like quantity of serum. The
solution in the serum was complete in 24 hours, while in the water there were
turbidity and deposit.

3. 10 centigrammes of the same salt were treated in the same way as in
the 2d case. In both cases the solution was not complete, but in the water
the deposit was double that in the serum.

These experiments were repeated at the temperature of the body with
the same results, with only the difference of a little greater solubility in the
water from greater elevation of temperature.

If the acid be a vegetable acid forming a salt of the alkaloids, this acid
obeys the usual law of decomposition, with a transformation into carbonic-
acid, and its combination with the base, but the undecomposable acids retain
their identity in the circulation in combination with the alkaloids.

As the salts of the alkaloids enter the circulation it would be reasonable to
anticipate that they can be detected in the organs. This is the case, as the
sulphate of quinia has been detected in the liver, and there is no doubt that
the other organs under favourable circumstances may evince its presence. The
secretions, however, present an open field for this investigation. By Landerer
it has been detected in the tears and in the milk, by the same experimenter
and M. Quevenne, in the effused fluid of dropsies. It has not been detected
in the sweat or the bile.

The most important secretion in which we may look for the sulphate of
quinia or its analogues is the urine. From the observations of M. Briquet it
appears that one-half if not more finds an exit by this route. This fact, first
stated by M. Piorry, was fully demonstrated by the experiments of Mess,
Levolley, and Fermond, under his auspices. Whether the portion of the salts
of cincbona not to be accounted for by elimination with the urine goes off
entirely by the other secretions, or is decomposed and worked up in the
economy like many other substances, is a point still remaining unsettled.

The mode of detecting sulphate of quinia in the urine recommended by M.
Briquet, is by the use of the iodo-iodide of potassium, which produces an
orange-brown precipitation. The formula which he gives for this test is 3j of
iodine, 3'j of iodide of potassium to f^viij of water. In his hands this solu-
tion will detect r^ff of the alkaloid in the solution, or a half centigramme
to the litre. This certainly is delicate manipulation.

For therapeutic purposes there are three points to be determined; first, the
time required for absorption; secondly, the sojourn of the salt in the organs;
and thirdly, the relation between the quantity administered, the quantity
absorbed, and the effects produced; each are considered.

Rapidity of absorption. — The time required for cinchona to affect the sys- •
tern has been variously estimated. Torti, Bretonneau, and others, have re-
garded it as twelve or more hours. Piorry regards the effect as immediate.
Two modes of determining this present themselves ; one, the search for the
existence of the substance in the economy ; the other, the observation of its
physiological effects : with respect to the first, all means of detection are diffi-

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[July

cult except in the urine, and to this secretion, then, have we to resort. M.
Briquet has found sulphate of quinia in this secretion in half an hour from
its ingestion, and at the end of two hours a most abundant precipitate was
produced by the test above stated. The observation of the physiological
effects leads to the conclusion that the time varies from a few minutes to a
quarter of an hour, with elevated doses (a gramme for instance), and that the
time required is longer with smaller quantities — in fact proportionable is the
time to the dose and its repetition. The limits which he places upon the action
of salts of the alkaloids of cinchona are from half an hour to two hours. This
consideration is important in connection with the treatment of cases according
to their urgency.

Quantity of the substances absorbed. — Experiment and observation show
that the quantity of the salts of cinchona taken up by absorption is always
in proportion to the quantity taken into the stomach — thus the abundance of
the precipitate in the urine is as the amount of substance administered : 8
grains of sulphate of quinia in twelve hours will give a yellow tint or light
cloudiness, while 30 will produce a deep precipitate. The constancy of the
precipitate is equally in direct relation to the quantity of the sulphate taken.

Mode of elimination. — As the alkaloids of cinchona and their salts belong
to inassimilable bodies it is necessary that they should be eliminated from
the economy as substances of like nature. According to the researches of
"VVoehler, Kramer, Orfila, Chatin and Bernard there are two modes for the
expulsion of matters from the economy: these are general and particular. In
the case of the articles under consideration, although the general emunctory
secretions, as the tears, mucus, saliva, &c. may discharge them in small amount,
yet the notable determination to the kidneys preponderating so greatly as has
been shown, almost determines this way to be the special one, constituting in
the sense just stated, the particular mode of elimination.

March of elimination. — With respect to this head the experiments and
observations of M. Briquet have given the following results : —

1st. The salts of cinchona are not as rapidly eliminated as certain other
substances, as the iodide of potassium, cyanuret of iron, of mercury, &c.
The rapidity of elimination has been previously given. The lingering in
the economy a greater time than the articles alluded to, has been supposed to
depend upon the organic nature of these substances.

2. When the elimination has once commenced, it continues with certain
regularity, and during the day of exhibition the urine maintains a current of
depuration. This is exhibited by the following experiment : Between 5
and 6 o'clock A. M., a patient took 20 centigrammes of the sulphate
of quinia, and at 8 o'clock was detected in the proportion of one centigramme
to the litre; at 12 M. of 5 centigrammes; at 4 P. M. of 10, and at 8 P. M.
of 10, were detected.

If, however, instead of divided doses, a single dose of 20 centigrammes is
given, the order is somewhat changed. In one hour in the proportion of 2
to 3 centigrammes are discharged; in 4 hours of 8; in 7 hours the same; in
11 hours of 5 to 6 centigrammes, and in 15, of 3 to 4 centigrammes. From
these experiments we may suppose that when the alkaloid is gradually intro-
duced into the economy, it penetrates the tissues in like manner, and not ex-
erting much reaction, is slowly expelled ; while on the contrary, introduced
suddenly it excites a reaction which causes it to be eliminated from the com-
mencement in considerable quantity. From this is deduced that when it is
desirable the medicine should not be expelled too rapidly, it should be admi-
nistered slowly and, gradually, and, in the language of M. Briquet, this is the

1857.]

Briquet, Cinchona and its Preparations.

157

reason why, when very large doses of sulphate of quinia have been taken at
ouce, no mortal effects have occurred, while such accident has nearly happened
when these quantities have been taken gradually.

3. The quantity of alkaloid eliminated * is always in proportion to the
quantity taken: thus when 20 centigrammes were taken in 5 doses at intervals
of an hour, 4 centigrammes were eliminated in 24 hours; when 30 c, 9 c ; 40
c. gave 12 c. ; 50 c. gave 14 c; 60 c. gave 20, &c. In the case of the dose
being administered at one time the same rule holds, only less of the article is
eliminated in the 24 hours, except where a high dose is given. There is
reason to think that the proportion is not maintained where either very small
or very large doses are given.

The rule which M. Briquet has observed to exist from sufficiently numerous
experiments, with respect to the entire amount eliminated, is as follows : that
when the salts of the alkaloids are given in moderate doses, and continued at
intervals during three or four days, one-third is expelled, and when taken in
one dose, daily, one-half is eliminated. He inclines to the view that what is
not expelled is used upon the economy, or burnt as the phrase now is.

Period of elimination. — This question is an interesting one. From an
analysis of the facts presented, M. Briquet comes to the following conclusion :
that the elimination is feeble on the first day of administration, gradually in-
creases during the following days, arrives on the fourth or fifth at a sort of
maximum, and goes on decreasing gradually, although the medicine continues
to be administered. The elimination continues after the medicine has been
suspended during a period varying from three to six days, whatever the time
during which the administration has been conducted. As the quantity which
should be eliminated is fixed, as has been before stated, if the elimination is not
abundant at first, it must continue a longer period. The reverse of which occurs
if the elimination is at first abundant. The mode of administration necessarily
influences the period of elimination ; when the salts of cinchona are given in
large quantity at once they are rapidly eliminated, when in fractional doses the
elimination is slower.

There are a number of circumstances which influence the action of the
salts of cinchona upon the economy. Age is one. From the experiments of
M. Briquet, supported by observation, it appears that young animals and chil-
dren are less affected by proportional doses than older animals and adults —
old people are easily affected : with respect to sex it appears that absorption
and impression are greater in females than in males, and with respect to condi-
tion, the most robust are less easily affected by these preparations.

M. Briquet concludes this part of his essay with observations upon the
influence of other modes of treatment or medication in several ways, upon
the system. These are extremely interesting, but we have no space for their
summary, or an extension of our essay by an analysis of the remaining chap-
ters, devoted to the therapeutic application and modes of administration. We
have already extended our paper beyond the limits intended at its commence-
ment, and must here close, presenting our apology for length in the full
exposition of the physiological portion of the subject — a portion of our infor-
mation upon cinchona of the highest consequence, and which heretofore has
never been so fully or satisfactorily elucidated. J. C.

No. LXVIL— July 1857. 11

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[July

Art. XII. — Traite de Chimie Anatomique et Physiologique, Normdle et Pa-
thologique, ou des Principes 'Immediats Normaux et Morbides qui con-
stituent le Corps de V Homme et des Mammiflres. Par Charles Robin et
F. Verdeil. 3 volumes, et Atlas de 45 Planches. Paris, 1853.

Treatise on Anatomical and Physiological Chemistry, Normal and Patholo-
gical; or of the Immediate Principles, Normal and Morbid, which constitute
the Body of Man and of the Mammiferse. By Charles Robin and F.
Verdeil. 3 vols., and an Atlas of 45 Plates. Paris, 1853.

This work is so important, and contains so many new views and new facts
which are very little' known, particularly in this country, that although three
years have elapsed since its publication, it cannot be considered too late now
to review it.

One of the authors of this treatise, M. Charles Robin, whose name already
ranks among those of the most distinguished anatomists of the age, is as well
known in America as in Europe. His collaborator, M. Verdeil, though much
less known here, has made some very interesting discoveries in chemistry and
physiology. His researches into the composition of urine and of the blood,
and especially on the existence of hippuric acid in this latter fluid, his dis-
covery of a new acid in the lungs, and his fruitful investigations on the vege-
table and animal colouring matters, have already placed him high among the
young European chemists.

The idea of writing this very original treatise of Physiological Chemistry,
belongs to M. Ch. Robin. While engaged in the composition of his great
work on General Anatomy, he found it necessary to describe first the chemi-
cal elements of the animal economy, and not being contented with the descrip-
tion of their physical characters, he was led to examine their chemical
history, and had, therefore, to ascertain where they are found, how and where
they are produced, how they may be extracted, what becomes of them, &c.
He soon felt the need of the aid of a chemist, and for this he could hardly
have had a more valuable assistant than M. Verdeil.

This statement partly explains the apparently strange title of the work
of Messrs. Robin and Verdeil. They call it Anatomical Chemistry, although
they do not mean by this title a chemical history of the elements of the body.
They wished to call their publication a treatise on the anatomy of the immediate
principles of the animal economy, as, for their purpose, they considered che-
mistry not as a science, but as an instrument, or rather as a means of dissec-
tion. But the publisher of their work, being afraid that it would not sell
so well with such a title, compelled them to give to it a more orthodox
appellation. They protest, however, against this compulsion, and declare,
in their preface, that they have not written a treatise on chemistry, but
that their work is a treatise on the anatomy and physiology of the imme-
diate principles, studied with the help of chemistry, natural philosophy, and
microscopy. Their work is the first of the kind which has ever been pub-
lished ; it gives a complete chemical, physical, anatomical, and physiological
history of the immediate principles, neglecting entirely the theoretical specu-
lations which fill the books of chemists.

The immediate principles which are the sole objects of this original work
are defined as follows by our authors, after M. Chevreul : the final products,
solid, fluid, or gaseous, resulting from a well conducted anatomical analysis
of the various humours and anatomical elements susceptible of no further
division without an alteration of their chemical nature.

1857.] Kobin and Verdeil, Anatomical and Physiological Chemistry. 159

The first of the three volumes of which this work consists, is devoted to the
general history of the immediate principles. After a long introduction, in
which the authors try to show that the science of the immediate principles
belongs to anatomy and not to chemistry, their first volume contains an expo-
sition of the characters of the immediate principles, their classification and
nomenclature, the means of analysis, and historical notions. The second and
third volumes contain a very complete exposition of all that was known at
the time the book was written, of each of the immediate principles and of
substances which have been erroneously considered as such.

In the first volume the authors insist upon their view that the study of the
immediate principles belongs to anatomy and not to chemistry; they show
that no matter by what means we separate a principle from humours or
from solids, in the state in which it exists in them, and without producing in
it any chemical alteration, we make a dissection, as well as when, with a
knife, we separate a nerve from a muscle or from an artery. They show that
the animal body is constituted of two sorts of elementary parts, the study of
which is the object of general anatomy — the immediate principles and the
anatomical elements.

They successively examine — 1. The mathematical characters of the imme-
diate principles (number, situation, volume, form, duration). 2. Their physical
characters. 3. Their chemical characters. 4. Their organoleptical charac-
ters (their impressions on our senses and on our various organs). 5. Their
organic characters. 6. Their variations according to sexes, ages, races, spe-
cies, and anormal or pathological states. 7. Their formation. 8. Their in-
fluence and their share in the organic or vital actions. 9, Their chemical
composition. 10. Their extraction and their chemical reactions. 11. Their
crystalline forms. 12. Their influence on light (polarization, double and
simple refraction, &c). 13. The influence of light upon them. 14. Their
solution in the liquids of the body. 15. Their influence as ferments or in
contact with ferment (catalysis, &c). 16. Their putrefaction. 17. Their
microscopical examination. 18. Their chemical reactions on the field of the
microscope. The most remarkable and original parts of this first volume are
those concerning the crystallography and the catalytic phenomena. There is
a complete treatise of the crystallography of the immediate principles, extend-
ing over a hundred pages.

Many views and facts, interesting to physiologists and physicians, are ex-
posed in the chapter concerning the catalytic phenomena, We will point out
some of them. It is known that in a catalysis a chemical change (a combi-
nation or a decomposition) takes place in many substances when they are in
contact with certain bodies. For instance, when an alkali, or a small particle of
fibrin, of silk, of cotton, or of humus, are placed in contact with the bioxide
of hydrogen, they decompose it; and, on the other hand, if platina, gold, char-
coal, and other porous bodies are placed in contact with hydrogen and oxygen
in the proportion required for the formation of water, this liquid is formed. In
these two cases the substances which produce a chemical decomposition, or a
chemical combination, do not participate chemically in what takes place;
they remain as they were without the slightest alteration. Messrs. Robin
and Verdeil try to prove that many of the phenomena of digestion, nutrition,
secretion, &c, are mere catalytic phenomena. Nobody considers the trans-
formation of starch into dextrine, and of dextrine into glucose under the influ-
ence of sulphuric acid a vital action; yet many persons are inclined to con-
sider as vital the same transformations when produced by salivary diastase.
The two phenomena are completely similar, and must have the same name;
if one is a catalysis, the other also is a catalysis.

160

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[July

The various organic catalytic bodies, sueh as the vegetable diastase, the
pectase, the synaptase, the myrosine, the animal diastase, the pepsin, all act
in the same way — that is, in producing chemical changes without being them-
selves submitted to any change. All these substances are products of altera-
tions of albuminous substances in animals and plants, and they have the same
elementary composition as the substances from which they have been drawn.
They do not exist as immediate principles either in plants or animals.

All the humours or tissues from which catalytic bodies are extracted, are
able to produce the same phenomena as these bodies separated from them.
So it is that saliva acts like diastase to produce the dextrinic, glucosic, and
alcoholic catalyses; so it is that the muscular, the serous, and the mucous mem-
branes of the stomach and of the bladder act like pepsin, &c. But this de-
pends, certainly, on alterations in these tissues or in the saliva, producing
there the catalytic substances (diastase, pepsin, &c).

When a catalytic body becomes altered, its influence changes; for instance,
when diastase has been exposed to damp air for two days, instead of changing
starch into glucose, it transforms this substance into lactic acid. It might
prove useful in certain cases of gastralgia, depending upon an excessive acidity
of the contents of the stomach, to examine if the primitive cause of the affec-
tion is not an alteration of saliva, having changed its properties so that it
transforms starch into lactic acid, and not into glucose.

Messrs. Boutron and Fremy have shown that various degrees of alteration
of a membrane enable it to produce different catalytic phenomena. So it
is that when fresh membranes are placed in contact with sugar, they suc-
cessively form, according to their degree of modification, lactic acid, mannite,
& viscous matter, and at last carbonic acid and alcohol. If the mucous
membrane of the stomach has been washed with a great deal of water, it
seems to have no catalytic influence ; but if left some time in water, it be-
comes altered and then transforms glucose into lactic acid. A dried bladder,
exposed to damp air, soon acquires the power of producing this same catalysis.

it has been imagined that the catalytic phenomena due to altered or putre-
fied animal matters result from some action of vegetable or animal organisms.
Messrs. Robin and Verdeil affirm that this view is erroneous. In the first
place, as it is known that vegetable organisms do not develop themselves in
alkaline liquids, and as putrefied animal matters are alkaline, these organisms
cannot originate there. Moreover the microscope shows that there are none
in or upon the putrefied matters. As regards the existence of animal organ-
isms, our authors have seen that putrefied meat without any trace of infusoria
;put with glucose under mercury determined fermentation in two or three
hours. Analogous experiments with other catalytic substances, such as dias-
tase, pepsin, acids, alkalies, etc., prove that their influence is entirely inde-
pendent of the formation of vegetable or animal organisms.

Messrs. Robin and Verdeil show that it is not the yeast plants (cryptococ-
cus and iorula) which are active in certain fermentations; but that it is the
altered gluten on which these vegetable organisms are developed.

It has been said that when infusoria were injected into the bloodvessels of
an animal, it died because those animalculae produce fermentation. It is true
that a fermentation then occurs and causes death, but it is only after the infu-
soria have died — and after their organic matter has become altered and even
dissolved that they cause fermentations.

From the facts above mentioned, and from many others, Messrs. R. and
V. conclude that the belief that fermentations and catalyses in and out of the
animal body are vital actions, is entirely erroneous.

1857.] Robin and Verdeil, Anatomical and Physiological Chemistry.. 161

In another part of their history of catalytic phenomena, our authors show
the distinction existing between fermentation, putrefaction, and the other
catalyses. The simplest catalyses are those in which mere transformations
or combinations take place. In fermentations there is a decomposition of
one substance into two or three, with production of heat and generally of
carbonic acid. In putrefactions there are phenomena like those of the sim-
ple catalyses and those of fermentation, with phenomena of combustion. We
owe to Berzelius the idea of the similarity of these three kinds of physico-
chemical phenomena (catalysis, fermentation, and putrefaction).

Messrs. R. and V. show that the attempts at an explanation of the catalytic
phenomena by imagining a catalytic force, or by supposing that electricity is
their cause, do not explain anything. Disciples of Auguste Comte, like him,
they do not admit the existence of forces ; they only admit that matter is
endowed with properties, which manifest themselves when the conditions
necessary to their manifestations exist.

We must refer the reader to the work of our authors for what relates
to the following catalyses : 1st, the hydric ; 2d, the nitrous ; 3d, the acetic ;
4th, the pectic ; 5th, the dextrinic or glucosic. But we will say a few words
on some other kinds of catalyses. Prof. Bernard and M. Verdeil have found
that blood has the property of transforming glucose into lactic acid. This
explains why glucose injected into the bloodvessels quickly disappears; and
also why the sugar produced in the liver disappears in the blood in the short
time of the passage between the liver and the lungs through the heart. If
too much sugar is mixed with blood this liquid becomes altered before the
lactic transformation is complete, and then the blood losing its ordinary cata-
lytic property and becoming a ferment, the remainder of the sugar is trans-
formed into alcohol and carbonic acid.

Another species of catalysis deserves a few remarks. Our authors admit
that pepsin is not a special product of secretion of the stomach, but simply the
gastric mucus altered by the air introduced with the aliments. They partly
base this view on the fact that animal matter from many organs may give
origin to pepsin when it is altered by air. The action of pepsin in digestion
they consider, with many physiologists, as merely catalytic.

Messrs. R. and V. describe many other kinds of catalysis and all the fer-
mentations and putrefactions. We have no room to analyze their interesting
exposition of facts on these subjects. We will merely say that they consider
the formation of most of the immediate principles, which take their origin in
the animal economy, as due to a catalysis. The catalytic body, that is, the
substance which without furnishing any element produces a chemical change
in other substances, is, in this case, the tissues or the blood. Albumen,
fibrin, casein, uric acid, etc., are formed in this way. The phenomena of
nutrition and secretion result from catalytic changes. We think that these
views, which previously had been proposed by other physiologists, are very pro-
bable, but that they still require demonstration.

Messrs. R. and V. admit as immediate principles some which had not been
considered as such before them, and they expel from the list of these princi-
ples many substances which they think have not been proved to be real imme-
diate principles, or which positively are not such. They divide their second
and third volumes, which are devoted to the special study of the immediate
principles and of other substances found in the animal body, into several
parts, as 1st, the real immediate principles; 2d, the accidental immediate
principles ; 3d, the badly determined principles, the doubtful principles, and
the bodies erroneously considered as immediate principles.

162

Reviews.

[July

We have arranged a few tables, which will give at a glance the list of all
the real and the probable immediate principles (or considered so by Messrs.
Robin and Verdeil) existing in man, and we indicate where these substances
are found in the normal anatomical elements and humours, and also in some
morbid, solid, or liquid substances.

CLASS I.

Mineral or Inorganic Immediate Principles.

Where found.

f !•

Oxygen . . . .

Everywhere.

Hydrogen ....

Everywhere.

1 3-

Nitrogen .....

Everywhere.

- 4.

Carbonic acid ....

Intestinal canal, blood, urine, expired air.

Carburetted hydrogen

Large intestine, expired air.

Sulphuretted hydrogen

Large intestine, expired air.

1 7.

Water .....

Everywhere.

- l.

Chloride of sodium ...

Everywhere, except in enamel of teeth.

Chloride of potassium . .

Milk, muscles, liver, blood, urine, bile,

gastric juice.

Fluoride of calcium ...

Bones and teeth.

Chlorhydrate of ammonia . .

Saliva, tears, urine.

1 5.

Carbonate of ammonia

Expired air.

fin TVinn a f p n"F limp

tubercles, etc.

Carbonate of magnesia . .

Blood, urine of some animals.

Carbonate of soda

Blood, lymph, urine.

Bicarbonate of soda .

Blood

10.

Carbonate of potash

Blood, saliva, brain-sand.

Sulphate of soda

Everywhere, except milk, bile, and gas-

tric juice.

| 12.

Sulphate of potash .

Everywhere, except milk, bile, and gas-

tric juice.

13.

Sulphate of lime

Blood, fecal matters, biliary calculi, pan-

creatic juice.

14.

Basic or neutral phosphate of lime

Everywhere, but particularly bones.

15.

Acid phosphate of lime

Urine.

16.

Phosphate of magnesia

Everywhere.

17.

Ammoniaco-magnesian phosphate

Sometimes in urine, calculi, fecal matters

in disease.

18.

Neutral phosphate of soda

Everywhere.

19.

Acid phosphate of soda .

Urine.

[20.

Phosphate of potash

Almost everywhere.

CLASS II.

Crystallizable Organic Immediate Principles.

1st Division.
Acid and
saline prin-
ciples.

1. Lactic acid

2. Lactate of soda

3. Lactate of potash

4. Oxalate of lime

5. Uric acid .

6. Neutral urate of soda

7. Acid urate of soda .

8. Urate of potash

9. Urate of ammonia .

10. Urate of lime .

11. Urate of magnesia .

12. Hippuric acid .

13. Inosate of potash

14. Pneumic acid .

15. Pneumate of soda .
[16. Taurocholate of soda

Gastric juice, muscles, sweat.

Blood tubercles.

Muscles and gastric juice?

Ur-ine.

Urine, urinary and biliary calculi.

Urine, gouty concretions, blood, urinary

calculi.
Urine, gouty concretions.
Urine, urinary calculi.
Urine, urinary calculi.
Gravel, urinary calculi.
Urinary calculi.
Urine.
Muscles.
Lungs.

Lungs, blood.
Bile.

1857.] Robin and Verdeil, Anatomical and Physiological Chemistry. 163

2d Division.
Neutral or

alkaloid
animal prin-
ciples.

3c? Division
Sugars.

f 1. Creatine .
j 2. Creatinine

-j 3. Urea

4. Chlorosodate of urea

5. Cystine .

1. Liver-sugar

2. Milk-sugar
1. Cholesterin

4 th Division.
Fatty sub-
stances and
soaps.

2. Serolin

Oleic acid
Margaric acid .
Oleate of soda .
Margarate of soda
Olein
Margarin
Stearin

"Where found.

Muscles, blood, urine, amniotic liquid.

Muscles, blood, amniotic liquid, urine of
some animals.

Blood, urine, vitreous and aqueous hu-
mours, amniotic liquid, saliva.

Urine, amniotic liquid ?

Gravel and urinary calculi.

Liver, blood, urine, lymph, chyle, cerebro-
spinal fluid.

Milk.

Blood, bile, liver, brain, nerves, crystalline

lens.
Blood.
Blood, bile.
Blood, bile.
Blood, bile, lymph.
Blood, bile, lymph.
Fats, blood, chyle, urine, eggs, milk.
Fats, blood, chyle, urine, eggs, milk.
Fats, blood, chyle, urine, eggs.

CLASS III.

COAGtTLABLE AND NOT- CRYSTALLIZABLE ORGANIC SUBSTANCES.

1st Division.
Liquid
organic

substances.

2c? Division.
Solid or
half solid
organic
substances.

3c? Division.

Colouring
or coloured
organic

substances.

1. Fibrin

2. Albumen

3. Albuminose

4. Casein

5. Pancreatine

6. The mucosines

1. Globulin .

2. Crystalline

3. Musculin .
■\ 4. Elasticin .

~ , Cartilagein
i Ostein

1^7. Keratin

1. Hematosin
! 2. Biliverdin
j 3. Melanin .

4. Urrosacine

Blood, chyle, lymph, liquid of ascites, and

of blisters, etc.
Muscles, blood, lymph, chyle, amniotic

liquid, etc.
Blood, chyle.
Milk, blood? arteries?
Pancreatic juice.
Mucus, urine, saliva.
Blood-corpuscles.
Crystalline lens.
Muscles.

Yellow ligament, arteries.
Cartilage, cornea.
Bone.

Hair, nails, horn.
Blood-globules.

Bile, biliary calculi, placenta, blood.
Pigment of the skin, the brain, and the eye.
Urine.

Probable or Badly Determined Immediate Principles.

1. Silica ......

2. Leucine

3. Xanthine . .

4. Hypoxanthine . . . .

5. Lienine .......

6. Two special acids ....

7. Hematoidin

8. Butyrine .

9. Caprine, caproine, and capryline ? .

10. Butyroleine . . . . .

11. Phosphuretted fats

12. Cerebral acid . .

13. Cerebrate of soda .

14. Neurine . . . .

15. Synovine

16. Lacrymine

17. Spermatine

18. Special albumen of dropsical liquid

19. Paralbumine

20. Pyine

Blood, muscles, hair, wool, saliva, bile, urine.

Blood, lungs, liver.

Urinary calculi.

Spleen.

Urine of man.

Blood crystallized.

Milk.

Nervous centres, blood, yolk of the egg.

Brain.

Nervous centres and nerves.

Synovia.

Tears.

Sperma.

Liquid of ascites.
Liquid of ovarian dropsy.
Pus.

164

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[July

One of the most interesting articles of the special parts of the treatise of
Messrs. R. and V. is that relative to fibrin. Of the various points concerning
the history of the coagulation of this principle, we will merely relate here
those which are not generally known, or which have been discovered or
ascertained by our authors.

1. Coagulation of fibrin begins soonest in the blood of weak individuals, of
those who have been exhausted by many bleedings, of patients who have long
been suffering from chronic diseases, and of those labouring under typhoid
fever. A cachectic state in animals seems to have the same influence as in
man on the rapidity of coagulation. One of the authors has seen the blood
of sheep affected with a chronic disease coagulating quicker than usual.

2. Fibrin coagulates in from 10 to 20 seconds; i. e. with extreme quick-
ness, when blood comes in contact with threads and thin rods, or with a
sponge or dust, which can absorb water.

3. In the liquid of ascites, M. Delaharpe has seen fibrin to coagulate a few
instants after tapping. This takes place when the liquid is left without agi-
tation ; but one of our authors has noticed that coagulation is delayed as long
as the liquid continues to flow into the vessel. The liquid of ascites often
contains fibrin enough to take the appearance of a trembling, opaline jelly,
which, by degrees, becomes more solid. In eases where there is not fibrin
enough for the formation of a jelly, filamentous fibrin may be obtained by the
aid of a feather, to which that substance will attach itself. One of the authors
has ascertained the exactitude of these facts advanced by M. Delaharpe.

4. According to M. Delaharpe a temperature a little inferior to that at
which albumen coagulates, prevents coagulation of fibrin in the liquid of
ascites. It would be very interesting to ascertain the truth of this statement,
as, if it were proved to be correct, it would be a very strong argument against
the recent theory proposed by Dr. Richardson, of London, in his prize essay.

5. Our authors admit the correctness of the view of M. Bouchut concerning
the cause of phlegmasia alba dolens, which view consists in the supposition
that fibrin coagulates in the veins, in this affection, not because they are in-
flamed, but because there is an excess of fibrin and a notable slowness of cir-
culation in the dilated veins of the inferior limbs. This last reason, i. e. the
stasis of the blood, our authors consider as the most important. In fact, they
try to prove that wherever the circulation is not rapid there is danger of coagu-
lation; so it is in various veins in hemorrhoids, in compressed veins, in cases
of senile gangrene, where the coagulation begins in the capillaries. They
show that arteritis has nothing to do with senile gangrene. If there be an
appearance of inflammation of the arteries, it depends on the coloration of the
cellular tissue, due to the accumulation of altered red corpuscles in the
capillaries.

6. When it is said that blood is found uncoagulated in cases of effusion
due to a contusion, it is very frequently a mistake. What is taken for
blood is only some reddish serosity, while the coagulated fibrin adherent to
the contused tissues is not seen, unless searched for elsewhere than in this
serosity.

7. The fibrin of the menstrual blood does uncoagulate when the propor-
tion of blood is small compared to that of the increased secretion of mucus.
As soon as the quantity of blood is greater than that of mucus, clots are
formed. This is important as a means of distinguishing real menstruation
from uterine or vaginal hemorrhage.

8. It is fibrin which forms the pseudo-membranes found on the skin or

1857.] Robin and Verdeil, Anatomical and Physiological Chemistry. 165

the mucous membranes in diphtheritis, also in the bronchise in certain forms
of pneumonia, and on the skin from the application of blisters. There is the
same thing in the so-called cantharidian cystitis, i. e. an exudation of fibrin,
which soon coagulates and forms a pseudo-membrane on the bladder and on
the urethra. One of the authors has observed that it is not albumen, but
fibrin, which forms this membrane. In all these cases fibrin, when coagulat-
ing, takes in the network it forms, some epithelial cells and often pus-
globules or corpuscles of blood.

9. At the surface of inflamed serous membranes there is an exudation of
fibrin which soon coagulates j but here the characters of fibrin differ from
those it presents on the mucous membranes or on the skin, on account of the
globules of pus mingled with it, and of the serosity which bathes it. In this
purulent serosity fibrin exists, perhaps liquid during life, but found coagu-
lated after death, in the pleura, the peritoneum, the pericardium, and even
the arachnoid and the synovial membranes. These clots contain globules of
pus.

10. The retractile power of coagulated fibrin must be studied separately
from coagulation. The retraction usually is very great in a coagulum which
has formed slowly. In the liquid of ascites the coagulum has less retractility
than that of chyle and lymph, and the coagulum of these last two liquids re-
tracts less than that of blood. Retraction is often prevented from taking
place, on account of the adhesion of the coagulum to the walls of the vase.
The fibrin of arterial blood has a greater power of retraction than that of the
venous blood. The formation of the buffy coat does not depend only on the
fact that coagulation takes place after the red globules have begun to sink,
but also and mostly upon the expulsion of still liquid fibrin, by the retraction
of the coagulum. This liquid fibrin in a short time coagulates, and as it does
not contain globules is without colour. Sometimes there are two distinct
layers in the buffy coat, on account of the formation of a second one during
the process of retraction.

it. The consistence of coagulated fibrin is sometimes so great that M.
Robin has been frequently consulted about layers of fibrin in the uterus,
which were considered as being possibly the mucous membrane of the organ.
This takes place particularly in dysmenorrhoea.

12. Coagulated fibrin does not become organized or vascularized, even on
the pleura. There are sometimes real membranes, containing fibrous tissue,
bloodvessels, etc., formed on the pleura, but they are entirely different from
the fibrinous pseudo-membranes. Sometimes, in this last deposit, red striae
are found, which have been erroneously considered as bloodvessels ; but the
microscope shows that these striae are formed by accumulations of altered
blood-corpuscles, and that they contain none of the elements of capillaries or
larger bloodvessels.

13. In the Graafian vesicles, the coagulum fills the cavity after the rupture
of the vesicle ; it is at first red, but quickly loses this colour. Sometimes 20
or 30 days after its coagulation, this fibrin becomes grayish, half transparent,
ordinarily, however, still a little reddish by the remnant of the colouring
matter of the blood. This grayish coloration belongs mostly to the corpora
lutea of pregnancy, because then the resorption of the clot is more rapid than
in the corpora lutea of menstruation, and what remains last is the fibrin. It
is this substance, no more coloured by globules, which has been mistaken for
plastic lymph by some writers. Resorption takes away the coagulated fibrin
of the corpus luteum of menstruation in six weeks or two days, while the

166

Reviews.

[July

coagulation of the corpus luteuni of pregnancy is not absorbed until after
the lapse of eight or nine months.

14. M. Delaharpe has found that the coagulated fibrin in the liquid of
ascites may be quickly dissolved. The liquefaction seems to be more rapid
in small than in large vases. In the latter, there are remnants of clots
twelve or fourteen hours after coagulation, while in the former the coagula
disappear in six or eight hours. One of our authors, however, has kept a
clot formed in a small vase for four days. He has ascertained, after M. Dela-
harpe, that when such a clot has been compressed it does not dissolve as it
would have done if the liquid of ascites were left in it.

15. Even the fibrin of blood after bleeding may dissolve spontaneously.
M. Delaharpe and others have often observed this dissolution in the soft
upper layer of the buffy coat. Beclard has found that the coagulated fibrin
of the portal or splenic blood, abandoned to the action of the air, becomes
liquefied in twelve hours, while that of the blood from the jugular vein loses
its water and becomes desiccated.

16. The assertion made in many books, that the nitrate of potash and
some other salts with an alkaline basis can dissolve fibrin, is entirely erro-
neous ; they alter it and facilitate its decomposition, but do nothing more.

17. The pus-like liquid matter found in the centre of old clots is not pus,
as many physicians have thought from a mere superficial examination. The
microscope shows that it contains fibrils or granulations of fibrin, but no pus-
cells. Some colourless blood-corpuscles, mixed with the fibrin-granulations,
have erroneously been considered as pus-globules.

18. The presence of fibrin in the liquid of ascites may be considered as a
proof that there is an inflammatory state of the peritoneum. In a case of
ascites depending upon cirrhosis of the liver, with obliteration of most of the
branches of the portal vein, there was no fibrin in the effused liquid. M.
Bouchut has found that the quantity of fibrin in the liquid of hydrothorax
decreased in three successive tappings, in proportion with the diminution of
the inflammation, so that in the third there were but traces of fibrin, while
the whole mass of the liquid coagulated after the first operation.

This short analysis of the important researches of Messrs. Robin and Yer-
deil concerning the anatomical, physiological, and pathological history of
fibrin, can give but a faint idea of their value. In anatomy and physiology,
the importance of descriptions is frequently more in the details of facts than
in the conclusions we draw from them. We will therefore call the attention
of those of our readers who desire more information relating to fibrin to
the work of our authors, and we will point out what they say on the non-
organization of fibrin, on its resorption, and on the characters of its fibrils
and granules, as among the most interesting portions of this work.

There is an important part of the history of fibrin which, we regret to say,
is not worthy of the rest in our authors' great work. It is that which relates
to the origin and the uses of this principle. They state as proved that fibrin is
formed in the blood by a transformation of albumen. The only fact they adduce
to establish this view (which they share with many other chemists) is, that it
has been found by Dr. Brown Sequard that when defibrinated blood is in-
jected into a limb separated from the body, there is fibrin of recent forma-
tion found in the blood flowing from the veins of this limb. But this ex-
periment does not pro\e that the newly formed fibrin comes from the albu-
men of the blood more than from the protein substances of the globules or of
the tissues. The author of the experiment does not agree with Messrs. Robin
and Verdeil, and he considers that this new fibrin more probably results

1857.] Robin andVerdeil, Anatomical and Physiological Chemistry. 167

from a transformation of the globules. He has ascertained that the number
of red globules diminishes in this case, while the quantity of albumen does not
seem to change notably. He believes also that a certain amount of this new
fibrin probably is furnished by the muscles, as he has ascertained that the
quantity of this newly formed substance is greater when the muscles through
which the injected defibrinated blood passes are thrown in contraction by
galvanism.

Messrs. Robin and Yerdeil have neglected to examine the important ques-
tion of the uses of fibrin. They speak of it only in mentioning the opinions
of various physiologists on this subject, and even their historical account, in
this respect, is very short. Materials are now abundant to build up a theory
concerning the physiological history of this principle. We will refer those
who desire to undertake this work to a very able and learned article by Prof.
F. G-. Smith (in a note in the last edition of Carpenter's Human Physio-
logy), in which he has tried to show that fibrin is an effete substance, which
is to be destroyed, and is not destined to contribute to the nutrition of albu-
minous tissues. Some decisive experiments of Dr. Brown Sequard show, at
least, that fibrin is not necessary for nutrition : he has found that blood, de-
prived of fibrin, may maintain or regenerate vital properties in muscles, in
nerves, in the iris, in the spinal cord, and in the brain. By recent researches,
the same physiologist has arrived at this unforeseen result, that the production
and the destruction of fibrin in a day are immense. From the experiments of
Lehmann concerning the blood coming from the liver, and those of Franz
Simon with regard to that issuing from the kidney, showing that there is a de-
struction of all or almost all the fibrin which the blood conveys to these glands
(except that which passes in the lymphatic vessels), it results, if we take
into account the quantity which arrives at these glands in a day and the pro-
portion of fibrin in it, that there are many pounds of this substance destroyed
in that period of time. And as the proportion of fibrin remains almost in-
variable in the arterial blood, it results that there is a formation of many
pounds of this substance in a day. We know where its destruction takes
place, but we are still to learn where the greatest part of it is formed. We
are aware that Gerber says he has ascertained that there is a production of
fibrin in the thoracic duct ; but, in admitting that he has not been mistaken,
this cannot furnish many pounds of fibrin in a day, and it must therefore be
produced elsewhere and in more considerable quantities.

Whether fibrin is formed from the albumen, and the albuminose of blood,
of chyle, and of lymph, or from the red globules of blood (which have re-
cently been positively proved to be a normal element of lymph, by our dis-
tinguished friend, Dr. Grubler, of Paris), or if it is formed from the elements
of muscular and nervous tissues, or from all these parts at once — in all these
cases there is an immense metamorphosis of either globuline, musculine,
neurine, or albumen, corresponding with the very large amount of fibrin
formed. These facts, with those ascertained by Schmidt and Bidder concerning
the considerable quantity of juices secreted (and absorbed) in a day by the
stomach, the liver, the pancreas, &c, contribute to show how immense is the
transformation of matter in the blood.

Much is yet to be learned in regard to the production of fibrin ; and the
following experiment, which has been performed by Dr. Brown-Sequard,
shows that new and unforeseen results might be obtained by those who
would make researches in the physiology of this substance. Magendie found
that when he bled an animal almost to death, and after having deprived it
of its fibrin, reinjected at once the blood drawn out, there was more fibrin at

168

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[July

a second bleeding, made on the succeeding day, than at tbe first. Dr. Brown-
Sequard has ascertained that the results of almost analogous experiments are
entirely different if the successive bleedings are made at once, one imme-
diately after the other, instead of leaving a day between them. After three
bleedings no more fibrin was found in the blood, and, after the death of the
animal, the blood being beaten with rods did not yield any fibrin. After an
hour or two it seemed to have a kind of partial coagulation, in the shape of
small jelly-like agglomerations, resulting more probably from the agglutina-
tion of the red globules with each other than from a coagulation of a very
small amount of fibrin, if there was any. It had been concluded from
Magendie's experiments (with which some facts observed in man by Andral
and by Becquerel and Rodier, seemed to concur), that fibrin may be formed
very quickly in the blood. The experiments of Dr. Brown-Sequard show
that this formation is not so rapid as it was imagined.1

Messrs. Robin and Yerdeil have studied the other protein-substances as
carefully as fibrin. Concerning the principal of these substances, albumen,
we will only mention a few of the facts and views related by them. They
say that it is not albumen which is found in synovia, in gastric juice, in
saliva, in bile, in mucus, &c, but peculiar albuminous substances. In the
pancreatic juice the substance which had been considered as albumen, differs
from it according to the researches of Prof. Bernard, M. Ch. Robin, and M.
Moyse. When the pancreatic juice is heated, the albuminous substance it
contains coagulates, as albumen would do, while if sulphate of magnesia has
been added to this juice, it loses the power of giving a coagulum when heated.
The serum of blood containing albumen, on the contrary, yields a coagulum as
usual after it has been mixed with sulphate of magnesia. There is therefore
a difference between the albumen of blood and the albuminous substance of
pancreatic juice. This last substance has some of the properties of casein,
but differs from it in being coagulable by heat.

The dropsical serosity is said to contain albumen; but there is a difference
between this albuminous principle and real albumen. M. Ch. Robin and
M. Moyse have found that this serosity has the characters of albumen when
treated by heat and acids; but when it is mixed with sulphate of magnesia
the liquid filtered is slightly troubled (instead of forming large white clots as
albumen) by the following reagents — alcohol, nitric acid, or heat. This de-
pends on the fact that on the filter the albuminous matter has remained,
solidified by the salt. Experiments have shown that in the purulent liquid
of pleurisy there is real albumen and another albuminous substance.

Messrs. Mialhe and Pressat have proposed views in relation to albumen,
which are in a great measure contradicted by Messrs. Robin and Verdeil.
Albumen cannot pass by endosmosis, through any membrane, according
to Messrs. M. and P., but our authors show that it passes through certain
membranes, as the pleura, for instance. Messrs. M. and P. think albumen
to be insoluble, and to exist in a granular state in the blood ; they have found
that the albuminous substances are converted in the digestive tube into an
amorphous or caseiform matter, which is in a transitory condition between
albumen and albuminose, and can be absorbed before it becomes albuminose.
This last substance is the one which, according to Messrs. M. and P., passes

1 This physiologist had performed these experiments to ascertain if urea could be
formed in blood deprived of fibrin, many chemists having said that urea is a trans-
formation of fibrin. He has found that normal urine, containing as much urea as
usual, was formed in dogs whose biood did not contain fibrin.

1857.] Robin and Verdeil, Anatomical and Physiological Chemistry. 169

in the urine in Bright' s disease in cases where heat and nitric acid produce
only a partial precipitate, which is soluble in an excess of nitric acid. Messrs.
Robin and Verdeil state that the assumption of the existence of albumen in
a granular state is merely imaginary, as nothing of this kind is seen in
blood. They admit, with every chemist, the existence of the new principle
(albuminose) found by M. Mialhe, but they disagree with him in many re-
spects. They state that albuminose is slightly coagulable by nitric acid, while
M. M. says that it is not at all. In opposition to the view of M. M. that
nutrition depends on albuminose and not on albumen, they remark that
albuminose disappears from the blood in cases of disease when no food is
taken, nevertheless nutrition continues, so that albumen may be employed
in the nutritive metamorphosis of tissue.

Lately much has been said concerning the presence of casein in the blood
of nursing and pregnant women. Our authors do not admit it to have been
proved that it is real casein which has been found in these cases; they
think albuminose has been mistaken for casein. Panum, of Copenhagen,
has found in the blood a substance coagulating by the addition of a small
quantity of acetic acid, and liquefied by an excess of this acid. Water also
seems to coagulate this principle. He thinks this substance to be analogous
to casein, because when it is mixed with all the principles of milk, except
casein, a liquid is obtained looking and tasting like milk, and coagulating in
the stomach of young animals. Our authors justly observe that "such ex-
periments cannot establish the nature of a principle. Messrs. Guillot and
Leblanc have mistaken albuminose for casein ; however, it is an interesting-
result of their researches that the quantity of this substance augments during
gestation, and still more in nursing women. In disease, even in pregnant
and in nursing women, it disappears from the blood. In stillborn children
there is none.

M. Verdeil has discovered a very important fact concerning the various
colouring matters. It was known that hematosin contains iron; it was known
also that there is iron in bile ; M. Verdeil has found that it is in the biliver-
din, which is the colouring matter of bile, that iron exists. He has ascer-
tained the presence of iron not only in the biliverdin extracted from bile,
but also in that extracted from the placenta, in which, particularly in dogs,
there is a good deal of biliverdin, as has been ascertained by M. Moulinie,
a pupil of M. Robin. Besides, M. Verdeil, with M. Harley, has found iron
in melanine, the black colouring matter of pigment; and M. Harley, in fol-
lowing the means employed by M. Verdeil, has also found iron in urrosacine,
the colouring matter of urine. It is remarkable that iron, according to the
discovery of M. Verdeil, exists also in the green colouring matter of plants.

Much has been published during the last ten years on the crystals of the
blood. M. Ch. Robin, who had, at first, been mistaken in doubting .that
these crystals were formed by an albuminous substance, has lately ascertained
the most interesting facts concerning their nature. Everywhere, where blood
is effused, these crystals may be found ; they are frequently met with in the
lungs, the brain, the spleen, and the liver; they often exist in malignant
tumours, in pus, &c. In a case of cancer of bone, M. Robin has found
perfect blood-crystals in the substance of cancerous cells. With M. Lebert,
he has seen crystals coloured in their extremities and not in their centre. This
fact, and some others, led him to think that these crystals are not composed
of hematosin, and that they are merely tinted by this colouring principle. Vir~
chow, at the same time, arrived at the same view as that of M. Robin, with
this difference, that he thought the crystals were formed by an albuminous

170

Reviews.

matter, while M. R. then refused to admit that albuminous substances can
crystallize. Lately M. R., in a paper read to the Sociele de Biologie (in
common with M. Mercier), has much advanced our knowledge on this sub-
ject. In a mass of apparently solid blood, extracted from a cyst of the liver,
of the size of a filbert, the microscope showed nothing but crystals. A
chemical analysis proved that these crystals differ from hematosin. M. Ro-
bin calls the crystallized substance hematoidin, as Virchow had done already.
In comparing the results of his analysis of hematoidin with those of the
analysis of hematosin by Mulder, M. R. finds, as the following table will
show, that the great difference is iu the existence of iron in one of these sub-
stances, and its absence in the other : —

Carbon

Hydrogen

.Nitrogen

Oxygen

Ashes

Iron .

Hematoidin.

1st Anal. 2d Anal.

65.04 65.85

6.37 6.46

10.50 10.50

17.89 16.97

00.20 00.20

Hematosin.

Art. blood. Venous blood.

66.49 65.75

5.30 5.28

10.46 10.57

11.15 11.97

6.66 '6.45

From these analyses it seems that hematoidin (the substance of the crys-
tals) is hematosin, having lost its iron and an equivalent of hydrogen and
oxygen. As the hematoidin employed by M. R. for his analysis was of a
deep red, and as he did not find iron in it (although he admits that there was
perhaps some in the ashes), he concludes that the colouring matter of blood
does not depend upon the iron it contains. We do not think he has proved this
point, because, as we have often found (and so has M. Robin himself and other
micrographers) quite colourless crystals of hematoidin, entirely similar to the
coloured ones, we think it very probable — as M. R. admitted in 1853, and
as Virchow has tried to prove — that when the crystals are red they owe
their colour to hematosin. As regards the crystals analyzed by M. Robin,
they were likely coloured by hematosin, in so small a quantity that its iron
was not found. M. Robin knows very well that a very small quantity of
hematosin may give a deep red colour to a large mass of organic matter.
However, whether M. R. is right or wrong in this respect, he seems at any
rate to have proved that there is a principle which he calls hematoidin, after
Virchow, which principle has the property of crystallizing, and the composi-
tion of which is very similar to that of hematosin. He has also rendered
it very probable that hematosin does not give crystals unless it loses its iron
and becomes hematoidin.

Messrs. Robin and Verdeil describe carefully, in their work, the pneumic
acid, which was discovered five years ago by M. Verdeil. It exists in the
tissue of the lungs, where it is formed. Our authors say it does not exist in
the blood, but they merely mean that it does not circulate with the blood, as
they admit that it decomposes a salt of this liquid, and to do so it must be
in it. At all ages this acid is found in the lungs of man and animals. Each
lung contains a few centigrammes. The two lungs of a guillotined woman
gave nearly five centigrammes (one grain). Some morbid conditions of the
lungs seem to increase its quantity. It is to this substance that the lungs
owe their acidity. It is not combined with the substance of the lungs, but
in solution in the water which imbibes this substance. It belongs to the
class of principles which are not taken ready formed from the blood, but are
made by the tissues. The participation of this acid in one of the most im-
portant functions of the body — that of respiration — renders its study very.

1857.] Robin and Verdeil, Anatomical and Physiological CJiemistry. 171

interesting. It decomposes the carbonate of soda, and perhaps also the car-
bonates of lime and of potash, and sets free the carbonic acid which is partly
at once expelled through the bronchiae. Thence, the formation of pneumate
of soda, a salt which M. Yerdeil has discovered in the blood.

The pneumic acid forms beautiful crystals belonging to the oblique rhom-
boidal type. They are colourless, transparent, and from one-quarter to two
centimetres long; they are generally disposed in rays emanating from a
centre.

Among the immediate principles which have been the objects of original
researches by Messrs. Robin and Yerdeil, some of the most important are
those of the urine. From their study of the constituents of this liquid they
conclude that many of these do not exist in it in the state in which they are
said to. This will be explained hereafter. The chapter on uric acid and
its salts is one of the most interesting. Many of the statements in works on
urine and in treatises of organic chemistry concerning uric acid, and even
its quantity and its formation, belong mostly to the history of the urates.
If, in the formation of these salts, the acid comes from organic substances,
while the base is taken from principles of mineral origin, it is nevertheless
certain that the acid is never free in the economy, except in the urinary
tubes and the urine, and therefore outside of the bloodvessels in which only
urates are found. Even in urine the presence of free uric acid is only acci-
dental or pathological in man and in the carnivora and omnivora. Not only
is uric acid the most frequent constituent of urinary calculi, but it has been
found in biliary calculi. Crystallized uric acid is very frequently found in the
urine in gout, in articular rheumatism, and in many inflammatory affections.
But then it is very probable, as Lehmann has tried to prove, that this acid
is separated from its salts by lactic acid. Uric acid in this case crystallizes
only after the urine has been expelled from the bladder. Crystals of this
acid are never formed in the bladder except in the uric gravel, a disease cha-
racterized particularly by this rapid crystallization of the uric acid.

In some accidental circumstances, such as the use of exciting substances,
as coffee either very strong or in large quantity, in persons who are not
accustomed to it, there is a deposit of crystals of uric acid in the urine. This
is the case also in persons who have drunk champagne or other effervescent
wines. It has been said that there is no uric acid in diabetic urine ; but M.
llayer has shown, on the contrary, that crystals of this acid are frequently
found in the urine of diabetic patients. In embryos, the free uric acid is
found only after the formation of the urinary organs, and probably a long
time after this formation. The constant presence of uric acid in urine is a
symptom either of a disease of the kidney or of some other affection. M.
Becquerel says that there is 0.398 to 0.526 parts of uric acid out of 1000
parts of normal urine, and Lehmann asserts that one gramme and ten centi-
grammes (22 grains) a day is the quantity of uric acid, when there is a
mixed food ; but these assertions mean only that there is in urine a certain
amount of urates from which it has been possible to extract the stated quan-
tity of uric acid.

Liebig admitted that there was uric acid dissolved in urine by phosphate
of soda, but this is not exact ; it is urate of soda which exists, and not free
uric acid. The acidity of urine does not depend upon uric acid, but mostly
upon other acids and the acid phosphate of soda. The chemists and physi-
cians who have stated that the grayish or rose deposits which are formed in
urine are simply uric acid mixed with a little animal matter, and not urates
of ammonia or soda, have been mistaken. M. Donne has proved that

172

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[July

crystallized uric acid cannot be dissolved by urine, while these deposits,
like the urates, may be dissolved. Other facts prove also that uric acid is
not free in these deposits. Proust was the first who gave this demonstration.
Marvis Wilson, our distinguished countryman, Dr. Frick, of Baltimore, and
M. Ch. Robin, have sometimes seen uric acid in the shape of dumb-bell crys-
tals. A great many forms of crystallized uric acid have been represented by
Donne, by Dr. Frick, and by Messrs. Robin and Verdeil in the atlas of the
work we are reviewing.

The neutral urate of soda exists in the urine of Carnivora ; it exists also in
the urine of Herbivora when they are deprived of food. It has been found in
blood in gout (Garrod). The deposit in urine of persons attacked with in-
tense fever is neither uric acid nor the urate of ammonia, but urate of
soda and a little urate of lime, with traces only of urate of ammonia. It is
said by chemists that the free uric acid and that of the urates are formed by
combustion from neutral nitrogenous matters ; but this theory, though gene-
rally admitted, is in opposition to the fact that uric acid, free or in urates,
is absent in the urine of herbivora, except when they are deprived of food,
and it is known that in the mass of vegetables that they eat there is almost
as much nitrogenized substance as in the food of carnivora.

The same mistakes have been made respecting hippuric acid as with regard
to uric acid : frequently the hippurates have been taken for this acid. It does
not exist free in the blood, and its presence in urine is only accidental or patho-
logical. Lehmann thinks that the excessive acidity of urine in fever is due to an
excess of hippuric acid. M. Robin has found a deposit of hippuric acid in a
vigorous man, who did not take exercise and used highly nitrogenized food ;
the quantity of this acid increased after he had taken excitants like coffee, wine
and other alcoholic liquors. Hippuric acid may be found in alkaline urine, as
Messrs. R. and Y. have ascertained in a specimen furnished by a dog. Bou-
chardat has found hippuric acid in the urine of two patients, and he imagines
that the symptoms in these two cases were striking enough to entitle him to
give the name hippuria to their affection. M. Bouchardat will not find, we
think, many persons to admit with him the existence of this pretended peculiar
affection in a sceptical age like ours, when Addison and his supporters cannot
obtain a general acknowledgment of the existence of a peculiar affection cha-
racterized by bronzed skin and disease of the supra-renal capsules, although
they have thirty times as many cases as M. Bouchardat, and numerous ex-
periments upon which to ground their opinion. The hippuric acid discovered
in blood by Messrs. Yerdeil and Dolfuss was probably combined with soda;
and Messrs. R. and V. show that there are probably always hippurates in the
blood. Liebig thought he had proved that there is always free hippuric acid
in the urine of man; but, as Messrs. Robin and Yerdeil justly remark, as he
employed chlorhydric acid to obtain the hippuric acid, he very likely produced
the decomposition of a salt. Prof. Bernard says that the hippurates disap-
pear from urine of herbivora when they are deprived of food. Messrs. R.
and Y. have found a notable quantity of hippurate of lime in the urine of
horses.

There are in the urine of man two acids resembling hippuric acid, which
seem to have been described for the first time by Mr. W. Marcet, and after-
wards by Messrs. R. and Y. One of these acids forms crystals belonging to
the type of the rhomloidal oblique prism. It is a weak acid, soluble in
ether, alcohol, and boiling water, but insoluble in cold water. When heated
it gives a peculiar smell different from that of the hippuric acid. The other
new acid, before crystallization, forms drops having a resinous appearance,

1857.] Robin and Verdeil, Anatomical and Physiological CJiemistry. 173

which, after 24 hours, and sometimes later, crystallize in such a way that
from the centre of each drop many crystalline needles radiate. These needles
are soluble in ether and alcohol, but not in water. When heated they give
no aromatic odour.

Messrs. Robin and Verdeil attribute the acidity of nrine, at least in maD
and dogs, principally to the acid phosphates of soda and of lime. Morin had
already ascribed to this last salt, and not to lactic acid, the acidity of the
urine. It is probable that this acid phosphate re formed from the basic
phosphate, giving a part of its basis to some of the acids of the urine. An-
other salt contributes to the acidity of urine : it is the acid phosphate of soda.
Messrs. R. and V. have ascertained that normal urine contains together the
neutral and the acid phosphates of soda. They explain very rationally why
the urine of herbivora contain a much smaller quantity of phosphates than that
of man and of the carnivora, and why it is the reverse as regards the car-
bonates. The salts whose acids are the tartaric, the malic, the oxalic, etc., are
abundant in the food of herbivora, and they are easily transformed into car-
bonates, which are excreted by the urine; while in carnivora the food (meat,
corn, etc.) being rich in phosphates, and containing but a small amount of salts
capable of being transformed into carbonates, yields to the urine more phos-
phates than carbonates. It is a very interesting fact, that while the acidity of
urine chiefly depends on acid phosphates, the alkalinity of the blood depends
partly on basic phosphates. Although the alkalinity of the blood is ordinarily
chiefly due to alkaline carbonates, they may be replaced by phosphates, as Lie-
big has already shown. It is this possibility of the reciprocal substitution of
phosphates and carbonates in the blood which explains why in man the alter-
nations of animal and vegetable diet is not injurious. The food of differ-
ent animals varying very much, their blood must also vary much. This is
fully proved by some experiments of M. Verdeil, who has analyzed compa-
ratively the ashes of the blood of various animals fed differently. The quan-
tities obtained by these analyses cannot be considered as absolute, but as the
means employed in the various analyses were exactly the same, the compa-
rison of the different results is a valuable one. The blood of oxen, being
taken as the type of that of herbivora, had only 3 per 100 of phosphates (of
soda and potash), while the blood of a dog fed on meat contained 12 per 100
of the same phosphates. The ashes of the blood of the same dog, fed on
potatoes, contained only 9 per 100 of phosphates, and the ashes of human
blood have about 10 per 100.

Changes in the biliary and the urinary secretions, according to the kind of
food, are as frequent as the above-mentioned changes in the blood. Messrs.
R. and V. insist upon the demonstration that the various conditions of acidity
and of alkalinity of the urine, corresponding with variations in food, &c, de-
pend chiefly on the state of the phosphates contained in the urine. The phos-
phates of soda (the alkali and the acid) having but very little stability, are
probably the principal causes of the alkaline and acid states of the urine.

A complete chemical, microscopical, and physiological history of urea is given
by Messrs. R. and V. They endeavour to show that chemists have not proved
that urea, as they maintain, is a product of the combustion of nitrogenized
substances. We think they are right in this respect, and we have already
mentioned an experiment of Dr. Brown-Sequard, which seems to demonstrate
that urea may be formed in blood deprived of fibrin, Messrs. R. and V, have
no difficulty in showing that chemists have no direct fact upon which to
ground their opinion, and that they content themselves with unproved asser-
tions. The recent researches of M. Bechamp, which show that albumen, in
No. LXVII. — July 1857. 12

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[July

presence of certain chemical reagents, and at a temperature very much higher
than that of the animal body, may be transformed in urea, do not prove
— although M. Dumas admits it — that urea results from a transformation of
albumen in the animal economy. The facts observed by M. Bechamp only
show that albumen, in certain conditions, is transformed into urea; they
do not prove that in entirety different conditions, the same thing takes
place. We believe that no physiologist or chemist has tried to prove that
butyric acid in milk is the product of a transformation of fibrin, because M.
Wurtz has found that in certain conditions this transformation takes place.
We must acknowledge, however, it is possible that in the living blood urea
may result from the transformation of albumen or some other nitrogenized
substance; but we repeat, that proofs of its being so have not yet been
given. The experiments of Messrs. Bernard and Barreswil, which have be-
come so interesting since the publication of French's views on uraemia, are
mentioned at length in the work under review. When the kidneys have been
extirpated, according to these physiologists the intestinal secretions increase
in quantity, and instead of being intermittent (taking place only during
digestion), they continue without interruption. A few hours after nephrotomy,
this increased secretion is manifest, and at the same time ammoniacal salts
are found in the intestinal liquid, although it is still acid and has not lost its
digestive powers. They think that urea remains unaltered in blood, and that
as soon as it is secreted in the intestinal canal it is dissolved in fluids in
which fermentations are constantly going on, and it ferments and is changed
into ammoniacal salts. They have ascertained that urea introduced into the
digestive canal of healthy dogs, soon disappears transformed into ammoniacal
salts. In the intestinal tube of a recently dead animal this takes place also,
but more slowly. The experiments of Prevost and Dumas had shown that urea
is found in the blood of animals after the extirpation of their kidneys, but it
remained to be explained why this principle existed there evidently, only after
about three days. The experiments of Messrs. Bernard and Barreswil give
this explanation. They show that as long as the animals remain strong, urea
is thrown off by the intestinal secretions, but when the animals have become
weak, urea is expelled only in small quantity, and then quickly accumulates
in the blood.

Messrs. B. and V. describe at length the various forms of crystallization of
urea and of its principal salts, and they have admirably represented these
crystals in their atlas.

There are two substances in the urine, which, like urea, are deserving the
attention of physicians — we mean creatine, and creatinine. One of them, crea-
tine, exists not only in urine and in muscles, but also in blood, where it has
been discovered by Messrs. Verdeil and W. Marcet. It is formed in muscles,
passes into the blood, and thence is thrown out through the kidneys. We will
remark about this substance, that it is very remarkable what little spirit of
original investigation there is among physiologists and physicians. Here is a
substance which exists normally in the urine — what becomes of it when the
renal secretion is suspended ? After Messrs. Prevost and Dumas had extir-
pated the kidneys to search for urea in the blood, twenty experimenters have
followed them and repeated their experiments, but the urinary secretions con-
tain many other principles (creatine, creatinine, uric acid, hippuric acid, &c),
and no one looks for them. There are numerous young physicians who could
solve the questions concerning these principles, as well as a multitude of other
questions, if they would but direct their attention to them.

Creatinine has not been discovered yet in muscles, where, very likely, it is

1857.] Robin and Yerdeil, Anatomical and Physiological Chemistry. 175

formed with creatine. It has been found in blood by Messrs. Verdeil and
Marcet, and it exists in urine. Beautiful plates, representing creatine and
creatinine, are given by Messrs. R. and Y.

Among the substances contained in urine, many chemists, after Berzelius,
place lactic acid; but it seems to exist there only accidentally. It exists nor-
mally in gastric juice. It has been said (Bouchardat and others) that lactic
acid is not secreted in the stomach, but formed there by the transformation
of glucose; but Prof. Bernard has shown that most of the glucose is absorbed
before its transformation into lactic acid; and he says, also, that when only
vegetable food, containing a great deal of starch, has been given to an animal,
the chyme is alkaline, and not acid as it should be if glucose had been trans-
formed into lactic acid. Lactic acid appears to be formed in the muscles.
The researches of M. Bernard and those of M. Yerdeil have shown that
glucose, coming from the food or from the liver, is quickly transformed into
lactic acid in the blood, during its passage from the liver to the lungs, through
the heart. In the lungs, it is probable that the lactic acid, with the pneumic
acid, decomposes the carbonate of soda, renders the carbonic acid free, and forms
the lactate and the pneumate of soda. Lactic acid has the power to take the
various alkalies combined with carbonic acid; so it is that in the stomach,
according to Bernard and Barreswil, and to Melsens, the lactic acid of gastric
juice decomposes the alkaline carbonates.

The action of lactic and of pneumic acids on carbonates is dwelt upon- in
many places by Messrs. Robin and Yerdeil, against the views of chemists ad-
mitting that most of the chemical changes in the body take place by a com-
bustion. We might say that the predominant idea with our authors while
writing their work is, that the animal body is not a fire-place where scarcely
any process but combustion takes place chemically. They maintain that
usually the chemical phenomena which occur in the animal body are much
more complex than those imagine who believe that combustion is the principal
process. They think that some of the phenomena are, on the contrary, more
simple than certain combustions. For instance, they suppose that the trans-
formation of albumen into musculin, in muscles, takes place by a mere cata-
lysis, muscles being the catalytic agent. We might give a great many exam-
ples to show their views in this respect; we will merely say that they suppose
that the kidneys act by their catalytic property on the blood, to form uric and
hippuric acids ; that the mammary glands act by their catalytic property on
the blood to transform albuminose into casein, and glucose into milk-sugar;
that the blood-corpuscles have the catalytic property of transforming albumen
into globulin, &c. We are afraid that Messrs. R. and Y., who are right in
almost everything they say against the occurrence of combustion in the human
body, have gone much further than the facts warrant in admitting that cata-
lysis is so frequent in the body.

Accordirfg to most chemists, the theory of respiration and that of animal
heat are based upon the hypothesis of a direct combination of oxygen with
carbon and hydrogen. They have only looked at the fact that there is-
oxygen absorbed, and carbonic acid and water expelled. They imagined that
oxygen in the blood, or in the tissues, was constantly burning some substance.
An eminent chemist says: " The oxygen of the blood, while passing into the
capillaries, destroys by a real combustion the tissues that have become unfit
for life; the carbon and the hydrogen of these tissues, at least in part, are
changed into carbonic acid and water to be expelled by the lungs. But
what form shall nitrogen take ? The most simple combination it could form .
would be ammonia ; but as this gas cannot exist free in the economy, nature

176

Reviews.

[July

has had to modify it. It has been sufficient for this to put the ammonia in
contact with carbonic acid, and to eliminate from this combination the ele-
ments of water for the production of urea. This principle being inert and
soluble in water, can pass without the least danger into the torrent of the circu-
lation, and be taken and rejected by the kidneys. Such is the origin of urea
in the economy. It may be seen that it is in some respects a burnt body re-
sulting from the oxidation of the nitrogenized matter of the body."

It is evident that these are only assertions; but chemists have not taken
the trouble to give proofs of their views. They say, for instance, that when
oxygen combines with carbon, it produces a certain quantity of heat, and so
also when it combines with hydrogen; now, it being known how much car-
bonic acid and how much water is eliminated in a given time, and how
much is absorbed in the same time, they find that from seven to nine-tenths
of the animal heat is produced in this way. But they do not take the
trouble of proving that there is in the body really a direct combination of
oxygen with carbon and with hydrogen. Nor do they take into account
the production of heat which results from the immense number of chemical
metamorphoses which are constantly going on in the blood and in the tissues.
The time has come, however, when the discovery of some decisive facts will
oblige chemists to abandon their theories; we will mention only the two fol-
lowing facts: M. Bernard has ascertained that there is an increase of more
than one degree Fahrenheit in the blood during its passage through the liver;
Dr. Brown-Sequard has found that the temperature of the body rises about
2° or 3° Fahr. during asphyxia.

Before concluding this review of the eminently useful work of Messrs. Robin
and Verdeil, we must say that it is enriched by a splendid atlas of 45 plates,
each of which contains from 15 to 20 figures, representing all the crys-
talline and other forms of the Immediate Principles. There is no other
work in which the principles of the urine have been more completely repre-
sented. Many of the plates are coloured, and all the drawings, except a few,
have been executed by M. Ch. Robin himself, and by M. Lackerbauer, one of
the most able artists of France. E. B — S.

1857.]

177

BIBLIOGRAPHICAL NOTICES.

Art. XIIT — A Claim of Priority on the Discovery of, and also the Naming of the
Excito- Secretory System of Nerves. By Henry Fraser Campbell, M. £>., of
Augusta, Georgia, U. S. A., Member of the American Medical Association,
etc. etc. 8vo. pp. 16.

As early as May, 1850, Dr. Campbell, in an essay on the influence of denti-
tion in the production of disease, read before the Medical Society of Augusta,
Georgia, and published in the Southern Medical and Surgical Journal for June
of the same year, in explaining the " two orders of phenomena which occur
during the period of dentition, viz., the convulsive, and the secretory," refers the
first to the excito-motory, and the second to an excito-secretory function of the
nervous system ; in the following words : —

" Let us inquire how far these phenomena are dependent upon dentition ;
and analogy with the excito-motory system will much assist us in our argu-
ment. We have seen that local irritation can, through this system, produce
convulsions, by the reflex function of the nerves ; the sensitive branches of the
fifth pair becoming excitory to the motor-spinal nerves ; and so, we may justly
infer, do these same branches, under certain circumstances, become excitor to
the secretory filaments of the sympathetic, distributed so abundantly to the intes-
tinal canal, by a transmission of this irritation through the various ganglia
with which it is connected. "

In the essay just referred to, we find the excito-secretory function of the
nervous system — there for the first time distinctly indicated — very fully dis-
cussed and elucidated, while the fact, that a continuance of the irritation,
through the medium of that function, alters, finally, the character of the secre-
tions furnished by the several organs implicated in the irritation, is formally
adverted to.

In May, 1853, Dr. C. presented to the American Medical Association an
essay on the subject of typhoid fever, which was published in the sixth volume
of the Transactions of that body. In this essay he assumes that all typhoidal
diseases are manifestations of disease through the agency of the secretory sys-
tem of nerves.

"While engaged," he remarks, in the preparation of the essay, "my atten-
tion was called to certain experiments performed by Mons. Claude Bernard, of
Paris, together with his deductions therefrom. On examination, finding that
they contained what, at the time, appeared to me the germ of a theory simi-
lar to mine, recorded in June, 1850, though M. Bernard refers to them as a set
of phenomena identical with those occurring in the cerebro-spinal system of
nerves, denominated excito-motory by Dr. Marshall Hall, while I had de-
duced this excito-secretory system (in 1850), saying, 'Analogy with the excito-
motory system will much assist us in our argument and further, inasmuch as
this distinguished gentleman's report presented itself to my mind at that time,
somewhat in the form of an announcement/7 I deemed it advisable to record
before the National Medical Congress, in a brief memoir, my claim to priority,
and to protest against the palm of originality being awarded to M. Bernard.

Which memoir, entitled " On the Sympathetic Nerve in Reflex Phenomena,"
was published in the sixth volume of the Transactions of the American Medical
Association, for the year 1853.

In this memoir Dr. C. remarks as follows, quoting the first sentence from
his essay published in 1850 : —

" 'In conclusion, let us define the position which, at the end of our investi-
gation, we feel warranted in assuming. It is the following : that in the anatomy

178

Bibliographical Notices.

[July

and physiology, as well as in the dependent analogies of the process of denti-
tion, we find ample ground for the opinion that the diseases pertaining to this
period may be dependent, and in many instances, are entirely so, upon the local
irritation attending the process, being transmitted through the cerebro-spinal
system of nerves, producing convulsive diseases in the motory apparatus, or
through the sympathetic, causing derangements of the secretory organs, par-
ticularly of the alimentary canal, by the sway which it exercises over the
arterial system from which these secretions are eliminated.' "

" In the above brief quotation, it will be observed, that the doctrine of the
reflex function between the cerebro-spinal and sympathetic systems is plainly
enunciated, and not only is the physiological fact noted, but we there also have
surmised the transmission of permanent irritation, or of paralysis from the
cerebro-spinal to the sympathetic system, giving rise to various aberrations in
nutrition and secretion. This opinion we have held for several years, teaching
to our classes that there existed between the cerebro-spinal and the ganglionic
system of nerves, a relation similar to that between the sensitive and motor
branches of the cerebro-spinal, and which Marshall Hall terms excito-moiory ;
while we have termed that between the cerebro-spinal and sympathetic systems,
excito-secretory."

The same views were reiterated by Dr. C. in a review of M. Trousseau's lec-
ture on the effects of dentition in nursing children, contained in the 13th
volume of the Southern Medical and Surgical Journal, No. L, published Janu-
ary, 1857.

We have thus a complete chain of evidence in support of the prior claim of
Dr. Campbell to the discovery of the excito-secretory function of the nervous
system — first distinctly named by him — and the public enunciation of his views
in respect to this function in juxtaposition, and contradistinction to the excito-
motory function as discovered and announced by Dr. Marshall Hall, of London.

Notwithstanding the repeated publication of the views of Dr. C. on this
point, since the early part of 1850, in a professional periodical of extensive
circulation, and exchanging with all the medical journals in this country, and
with many of those of Europe ; in the Transactions of one of the most authori-
tative and dignified medical associations of the United States, their being
noticed formally in several of the leading medical journals of America, and,
in pamphlet form, distributed widely to scientific men on both sides of the
Atlantic, Dr. Marshall Hall, without either directly alluding to the fact that,
seven years previously, Dr. C. had pointed out, in express terms, the excito-
secretory nervous function, with a clear recognition of its relations to pathology,
through which, indeed, he has mainly deduced its physiology, makes, in the
London Lancet, for March, 1857, the following announcement: —

"In a memoir read at the Royal Society, in February, 1837, 1 announced the
existence of an excitomotory system of nerves. I believe I may now announce
a system or sub-system of excito-secretory nerves, not less extensive. "

In his subsequent remarks, Dr. H. refers to the experiments of M. C. Bernard,
of Paris, as confirmatory of his views in respect to the new nervous function
of which he treats.

"The most remarkable proof," he says, "of the doctrine which I am en-
deavouring to unfold is furnished by the brilliant discovery and skilful experi-
ments of M. CI. Bernard."

He here refers to the well-known experiments of this gentleman on the
pneumogastric nerve in its relation to the secretions of the liver, published in
his lectures on experimental physiology, during the winter session of 1854-55.

In a former part of his communication Dr. Hall remarks : —

" Henceforth the Diastatic Nervous System must be divided into two sub-
systems :"

"I. The excito-motory."

" II. The excito-secretory."

" The former is extended to the entire muscular system, the latter is diffused
over the general system as the blood is diffused over the system."

Again, in reference to the Pathological relations of the excito-secretory sys-
tem, he remarks : —

1857.]

Campbell, Excito- Secretory System of Nerves.

179

" The pathology of the excito-secretory sub-system remains to be investigated
and traced. A partial keen current of air, falling on any portion of the skin,
may induce inflammation in any susceptible internal organ. An extensive
burn or scald is apt to produce pneumonia."

In conclusion, Dr. H. remarks :

" My present object is only to draw the merest sketch of this vast subject,
which demands a most extensive and cautious series of experiments and obser-
vations. The efforts of many laborers, through many years, will be required
fully to develop the two sub-systems of the diastaltic nervous system. "

From the general manner and tone of the communication of Dr. Hall, it
must be very evident that he desires his announcement of the excito-secretory
nervous system of nerves should be received as that of a discovery of which he
alone is the author. And yet, whoever will take the trouble of comparing the
several communications published by Dr. Campbell, since May, 1850, with the
one of Dr. Hall, to which reference has just been made, must acknowledge that
the very same views of which the latter claims to be the author, and the same
pathological inferences deduced by him from those views, were announced by
the former many years previously.

Now it cannot but be looked upon as a somewhat surprising circumstance that
no one of the repeated publications of Dr. Campbell, setting forth his views in
reference to the existence of an excito-secretory system of nerves, and their
agency in the production of certain pathological phenomena; that no one even
of the many notices of these views that have appeared in standard medical
journals, during the last seven years, should ever have met the eye of Dr.
Hall, more especially when we consider the efforts that Dr. Campbell has made
to give to one, at least, of those publications a somewhat extended spread, and
to direct to it the notice of the leading physiologists of Great Britain. It is,
nevertheless, very possible that such may have been the case. We can hardly
accuse a scientific gentleman, occupying the high position that Dr. Hall does,
of so contracted a spirit of jealousy as would prompt him intentionally to over-
look the undoubted claims of an American physician to a discovery, which, if it
shall be finally established by experiment and observation, is as brilliant and
important as his own in reference to the excito-motory system of nerves.

We feel very confident that now the claims of Dr. Campbell have been laid
before him in so clear, candid, and kindly a manner as they are in the publi-
cation before us, Dr. Hall will promptly acknowledge that, in his supposed dis-
covery of a system or sub-system of excito-secretory nerves, and in its applica-
tions to pathology, he has been anticipated by his American contemporary.

In the mean time, we hold it to be our duty to sustain Dr. Campbell in his
claim to priority, which we believe no one will deny has been most triumph-
antly established.

Since the foregoing notice was written and in print, we have received the
number of the London Lancet for May, 1857, containing some remarks by Dr.
Hall, in regard to Dr. Campbell's claim. In these are freely and candidly con-
ceded to Dr. C. the priority of the idea and designation of an excito-secretory
nervous action. The following are the concluding sentences of the remarks
referred to : —

" I arrive at this conclusion : the idea and the designation of an excito-secretory
action belong to Dr. Campbell, but his details are limited to pathology and ob-
servation. The elaborate experimental demonstration of reflex excito-secretory
action is the result of the experimental labours of M. Claude Bernard.

" My own claim is of a very different character, and I renounce every other.
It consists in the vast generalization of excito-secretory action throughout the
system.

" There is, perhaps, not a point in the general cutaneous surface in which
tetanus — an excito-mofor effect — may not originate ; there is scarcely a point
in which internal inflammation — an excito-secretory effect — may not be excited.

"Every point of the animal economy is in solidarity by a reflex excito-secre-
tory action with every other !

" I here observe that this excito-secretory action cannot be designated dia-
staltic. It is certainly dia-energetic ; but it does not assume the form expressed

180

Bibliographical Notices.

[July

by the Greek term tittiXic. A new designation is required, and I propose at
once the plain and simple one of dia-centric. Thus the in-going nerves are
centripetal; their influence traverses the spinal marrow, and is dia-centric; it
is reflected along centrifugal nerves.

" One remark more. The diastaltic system extends to the internal muscular
organs, as well as the external. I would therefore speak of —

"1. External diastaltic action; and of

"2. Internal diastaltic action.

" The former has been amply elaborated and traced in my various publica-
tions ; the latter remains for new investigation.

"The former applies to all orifices and exits, and all tubular structures lead-
ing to them ; the latter to all internal muscular organs — the heart, the stomach,
the intestines, &c.

"I trust Dr. Campbell will be satisfied with my adjudication. There is in
the exciio-secretory function, as applied to pathology, an ample field of inquiry
for his life's career, and it is indisputably — his own. He first detected it, gave
it its designation, and saw its vast importance." D. F. C.

Art. XIY. — Reports of American Institutions for the Insane.

1. Of the New Jersey State Asylum, for the year 1856.

2. Of the Pennsylvania Hospital for the Insane, for 1856.

3. Of the Pennsylvania State Hospital, for 1856.

4. Of the Western Pennsylvania Hospital, for 1856.

5. Of the Mount Hope Institution, for 1856.

6. Of the North Carolina State Asylum, for 1856.

7. Of the South Carolina State Asylum, for 1856.

8. Of the Indiana State Hospital, for 1856.

9. Of the Illinois State Hospital, for 1856.

10. Of the Missouri State Asylum, for 1856.

11. Of the California State Asylum, for 1855.

1. From the very brief report by Dr. Buttolph, of the New Jersey Lunatic
Asylum, we make the following extracts : —

Patients in the asylum, Dec. 31, 1855 .
Admitted in course of the year
Whole number in course of the year .
Discharged, including deaths
Remaining, Dec. 31, 1856 . .
Of those discharged, there were cured
Died . . . . . . .

" The number of deaths was comparatively large, from its frequent occur-
rence from general exhaustion and consumption, in chronic cases ; about two-
thirds of the whole number being of this character. The general health of the
inmates has otherwise been unusually good through the entire year.

"Forty-nine more cases have been under care during the past, than in any
preceding year."

Whole number of patients from opening
Discharged, recovered
Died

Men.

"Women.

Total.

107

126

233

168

187

214

401

138

124

139

263

Men.

Women.

Total.

513

551

1,064

192

219

411

140

The report is embellished with an engraved view of the asylum, taken since
the two new wings were erected.

1857.]

American Insane Hospital Reports.

181

Men.

Women.

Total.

120

110

230

IGG

194

202

39G

172

110

114

224

2. The abstract of the medical history of the Pennsylvania Hospital for the
Insane, for the year 1856, is as follows : —

Patients at the beginning of the year .
Admitted in course of the year . ,
Whole number .....
Discharged, including deaths
Remaining at the end of the year
Of those discharged, there were cured
Died .

Causes of Death. — Typho-mania, 7 ; softening of brain, 3 ; tubercular con-
sumption, 3 ; chronic diarrhoea, 3 ; congestion of the brain, 1; suicide, 1; dy-
sentery, 1 ; "gradual exhaustion, induced by high mental excitement, want of
sleep, and a steady refusal of food/' 3.

The amount of matter in this report, which we wish to lay before our read-
ers, is so great, that we must quote with as little comment as possible.

"Of the admissions during the past year, several were of a peculiarly inte-
resting character. Among these may be noted a little girl scarcely five years
old, two sisters from this State, two sisters from South America, and a gentle-
man and his wife, none of whom were known to have a hereditary tendency to
insanity "

The first case alluded to in the following extract is interesting in its medico-
legal relations : —

"A case of highly-marked mania was received, in the early stages of which
the obscurity of the symptoms led to a criminal conviction, but which, in their
ultimate development a few weeks afterwards, were so striking — ending, indeed,
in death — that no one could well doubt the existence of the disease at the time
of trial. A few cases have also been under care, in which, although the evi-
dences of the disease were obvious enough to those familiar with insanity, a
careful judicial examination and subsequent developments seemed necessary
to satisfy all of the propriety of their detention." * * * * *

" While there may be, on one side, an apparent desire to make out individuals
to be sane who are really not so, there seems also to be a growing disposition,
in some parts of the country, to convert into insane men those who have not the
slightest grounds for the benefit of such a plea.

"Important as it is, on every account, that cases of insanity should be sub-
jected to proper treatment in their early stages — and this, all experience has
conclusively shown, can rarely be attained, except in institutions specially pro-
vided for the care of those afflicted with this malady — still, it is equally desirable
that none but proper cases should be received, and especially so that persons
guilty of crimes against society should not, without good cause, be relieved from
any past responsibility for their acts, on the ground of a mental condition which
deprived them of all power of self-control. The plea of insanity is often a most
righteous one, and altogether too humane in its character to have its just influ-
ence jeopardized by being used by those whose only claim to be shielded by its
benevolent influences consists in the atrocity of their offences or the enormity
of the frauds they have perpetrated on the community. Gigantic frauds and
startling crimes do not constitute insanity, nor are they to be regarded as the
symptoms of the disease ; and if our courts should once begin to permit such
doubtful associations, the sound common sense of the community, it is to be
hoped, will soon decree that for that form of insanity — no matter whence it
derives its title — the most efficient treatment will be found in some well-con-
ducted penal institution.

"To the medical profession belongs the high honour of having, on numerous
occasions during the last half century, interposed the plea of insanity success-
fully to save individuals who were really irresponsible for their acts, and who
otherwise must have suffered the ignominy and punishment of felons. The
justice and extreme importance of this plea, to those who are really insane,
make it incumbent on the same profession, and especially on those who have
the immediate guardianship of that afflicted class, to take care that they should

182

Bibliographical Notices.

[July

not be deprived of what rightfully belongs to them, and, at the same time, lead
them to frown upon every attempt, from whatsoever quarter it may come, to
put crime on a footing with disease, or to confound one of the heaviest of human
afflictions with the recklessness, extravagance and depravity of our race. Even
when conviction is avoided on the ground of insanity, there are certain forms
of the disease that seem to require that permanent seclusion should be one of
the results of such an acquittal. "Where life has been taken or attempted, and
a homicidal propensity has been shown to have existed, there can scarcely be
a greater judicial farce, or a scene better calculated to bring legal proceedings
into disrepute, than that an individual, through whose instrumentality some
one's life had been lost or seriously jeopardized, should, a short time after
such a trial, be seen walking in our midst, as openly as before the occurrence."

Men. Women. Total.

Whole number of patients since opening the

hospital 1,541 1,377 2,918

Discharged, cured 752 673 1,425

Died 177 137 314

" The ratio of the recoveries on the admissions for mania amounted to 59 per
cent. ; for melancholia, to 51 per cent. ; for monomania, to 42 per cent. ; for
dementia, to 11 per cent. ; and these last were nearly all of that acute form
which is occasionally met with. Of those registered as delirium, only 9 per
cent, recovered. The total number of recoveries amount to 48 per cent, of all
the admissions, or 52 per cent, of the discharges."

" The mortality from mania is 9 per cent, on the admissions for that form of
insanity; 8 per cent, from melancholia; 3 per cent, from monomania; 38 per
cent, from dementia; and 81 per cent, from delirium. The mortality on the
total of admissions is 10 per cent."

"The use of opium is recorded as the cause of insanity in four men and six
women. It probably has affected more eases, but these were unquestionable.
There is reason to fear that this most pernicious habit is on the increase. Five
cases were clearly attributable to the use of tobacco. Common as is the use of
this article, in some of its various forms, its injurious influence on many con-
stitutions is much more serious than is commonly supposed, and not unfre-
quently the cause of exceedingly troublesome and obscure nervous affections,
which cannot be cured whilst its use is persisted in. The effect on many insane
patients is so striking, that an intelligent attendant is often able to say, without
difficulty, when it has been used to any extent."

By comparing the whole number of the insane persons of certain professions
and occupations admitted into the Pennsylvania Hospital for the Insane, and
the Pennsylvania State Hospital at Harrisburg, with the whole number, accord-
ing to the last census, of persons who in Pennsylvania were engaged in those
professions and occupations, Dr. Kirkbride finds the proportion of the insane
to be relatively as follows: —

Lawyers . . 1 to every 178

Clergymen . 1 " 557
Teachers .1 " 578'

"Farmers . . 1 to every 977

Merchants . . 1 267

Clerks . . 1 " 336

Physicians . . 1 239

"There is also another interesting fact made out pretty clearly, and that is,
that any respectable occupation is better for mental health than having none
at all; the number of admissions of males here with ' no occupation' being as
high as 212, and, without doubt, showing a higher proportion, relatively, than
any of the callings referred to in the table."

By a comparison of his patients with the inhabitants of the State, in reference

to age at the origin of insanity, Dr. K

Under 10 years
Between 10 and 15

10 " 20

15 " 20

arrives at the following results :-

1 case for 92,817 persons.
1 " 5,035 "
1 " 1,445 "
1 " 801 "

1857.]

American Insane Hospital Reports.

183

138

112

250

129

212

167

379

146

130

103

233

Between 20 and 30 .... 1 case for 387 persons.

30 " 40 .... 1 " 398 "

40 " 50 .... 1 " 484 "

50 " 60 .... 1 " 572 "

60 " 70 .... 1 " 1,032 "

70 " 80 . . . . 1 " 1,521 "

The subscriptions for the new hospital building amount to $209,000. The
first stone of the building was laid on the 7th of July, and the corner-stone was
formally laid on the 1st of October, 1856. Upon the latter occasion, addresses
were delivered by Professor George B. Wood and others.

Men. "Women. Total.

3. At the Pennsylvania State Lunatic Hos-
pital, the number of patients, on the 31st
of December, 1855, was

Admitted in course of the year .

Whole number .....

Discharged, including deaths

Remaining, Dec. 31, 1856 .

Of those discharged, there were cured

Died

Died from exhaustion of chronic mania, 16 ; dysentery, 9 ; inflammation of
the lungs, 2; erysipelas, following inflammation of the throat, 2; suicide, 1 ;
chronic bronchitis, 1 ; acute mania, 1.

One of the patients, the death of whom is ascribed to chronic mania, had a
disease which corresponded in all essential respects with the disease of the
supra-renal capsules, as described by Dr. Addison, of London. " The skin of
the face and hands, particularly, was of a deep coppery-brown; her body in-
clined to emaciation, but the bodily functions were generally regular. Her
constant complaint was her great weakness ; but neither tonics nor malt liquors,
which she was constantly craving, seemed to have any beneficial influence."
There was no autopsy in her case.

" During the early part of the year," remarks Dr. Curwen, "our household
enjoyed an unusual degree of health; but, on the 1st of July, an epidemic
dysentery, which prevailed extensively in the neighbourhood, made its appear-
ance, and continued for six weeks, when it disappeared almost as suddenly as
it had appeared. Eighty-four patients and fourteen officers and attendants were
attacked ; and nine patients and one attendant died. Many of the cases were
severe and very protracted, and in several cases death was clearly to be attri-
buted to our inability to keep up a systematic medication, from the obstinate
refusal of the patient to take the means prescribed."

" During the last quarter of the year another epidemic extended from the com-
munity around us to our household, and presented many cases of an anomalous
character. Commencing as a violent inflammation of the fauces, in several
cases it extended so as to include all the glands of the throat and mouth, with
the tongue, so as entirely to prevent articulation and even deglutition, but
gradually subsiding in the course of a few days. In others, as the violence of
the inflammation of the fauces abated, erysipelas of the face appeared, involv-
ing the whole head ; and in others, again, the affection was confined entirely
to the fauces, and was quite obstinate. During the same period a disposition
to the formation of large, very painful boils, on every part of the body, very
tedious in their course and in healing, prevailed very generally."

Dr. Curwen alludes to the prejudice and misapprehension still existing in the
minds of the people in regard to institutions for the insane. For the purpose
of disseminating correct information, the old and injurious custom of permit-
ting visitors in general to pass through the wards is continued. Although the
inmates have frequently objected to it " as excessively distasteful and annoy-
ing," yet " it was hoped that the ultimate benefit to the community would
counterbalance the temporary annoyance to the individual."

184

Bibliographical Notices.

[Joly

4. The report of the Western Pennsylvania Hospital contains the subjoined
statistics of its department for the insane —

Patients admitted since the opening of the hospital . . . 132

Cured . 65

Died 9

Remaining, December 31, 1856 . 39

The only information additional to that which we have already published in
regard to the contemplated construction of hospital buildings upon the farm
purchased for that purpose upon the banks of the Monongahela, is contained in
the following extract: —

" The Board anxiously await such augmentation of their resources as, com-
bined with the legislative appropriation of thirty thousand dollars, will justify
them in commencing a building of ample size, upon the most improved con-
struction, capable of containing two hundred and fifty patients, a plan of which,
prepared under the supervision of Dr. Curwen, has been approved by Governor
Pollock."

Men.

Women.

Total.

122

115

110

127

237

114

123

5. At the Mount Hope Institution the statistical record for the year 1856 was
as follows : —

Patients, on the 1st of January .
Admitted in course of the year .
Whole number ....
Discharged, including deaths
Remaining, December 31
Of those discharged, there were cured
Died . . . ' . v . .

" The pathological condition to which death might be chiefly attributed ap-
peared to be as follows : To extensive pulmonary disease, three ; to acute
mania with intense cerebral excitement, five; to exhaustive mania, two; to
paralytic affections, two ; to strangulated umbilical hernia, one; to perforating
ulcer of stomach, one ; to erysipelas of head and face, one.

" Two patients were discharged cured, after being Jive and three and a-lialf
years inmates of the asylum. Recoveries like these two tend to show that
hope must not be abandoned in any case, however unpromising or protracted.

" Every day's experience convinces us that insanity often exists for months
without being recognized by the friends and relatives of the individual.

" Certainly, among the causes of insanity an unsubdued temper and the loss
of self-control stand prominently forward. Indeed, it has been said that every
one could, by an effort of the will, prevent the development of insanity. This
affirmation is, perhaps, too sweeping ; but, in a certain sense, it is correct.

" Parents have little conception of the nature of the evils they are engender-
ing for their favourite children, by giving way to their caprices and fancies,
and fondly gratifying all their wishes.

"Kindness with decision, regulated by justice and an earnest, heartfelt sym-
pathy, never fails to gain the confidence of the insane patient. We should be
particularly guarded never to make a promise which cannot be faithfully and
fairly performed."

A large part of Dr. Stokes' report is devoted to subjects heretofore very fully
discussed in our notices.

6. The report before us is the first which has emanated from the State insti-
tution of North Carolina since it was opened for the reception of patients. The
Superintendent, Dr. Edward C. Fisher, seizes the occasion to pay a tribute of
thanks to Miss D. L. Di^, for her " heroic and untiring efforts in originating
and prosecuting with success the law establishing and building the Asylum."
He remarks that the " building will be found to have been as substantially
and neatly executed as is deemed desirable in an institution of the kind, its
external appearance presenting a degree of symmetry and beauty rarely com-

1857.]

American Insane Hospital Reports.

185

bined in one of its extensive dimensions ; while the interior possesses an air of
cheerfulness and an amount of ventilation rarely met with/'

The first patient was admitted on the 22d of February, 1856. It was a case
of violent mania ; and this person " was the first to be discharged, some months
afterwards, entirely restored."

Patients admitted from Feb. 21 to Oct. 31,

1856 . .

Discharged, including deaths
Remaining, Oct. 31 ....
Of those discharged, there were cured
Died .......

Men.

Women.

Total.

Causes of Death. — Epilepsy, 1 ; exhaustion, produced by abstinence from
food, 1.

"During the hot weather of July and August, there occurred some thirty
cases of an endemic form of dysentery, which yielded readily, however, to
treatment."

We make the following extract from Dr. Fisher's exposition of the evils
arising from the deception of patients in removing them from their homes to
the hospitals intended for them : —

"As soon as the arrangements for the journey are made, a frank and kind
statement of the proposed journey, the place in view, with the object sought,
should be made. If, upon this representation, there should (as may sometimes)
occur an unwillingness on the part of the patient to accompany them, and
subsequent efforts to bring about a compliance with their wishes be alike
unsuccessful, resort must then be had to such coercive measures as will be
found necessary."

" Far better will it be to resort, if necessity compels it, to personal restraint,
than to any expedient or false representation by which ' truth will be com-
promised/ to secure a compliance."

" A striking evidence of the evil consequences resulting from fictitious repre-
sentations, is furnished by one of the inmates of the Asylum at this time, who,
under the belief that by the presentation to the Governor of the State of a spu-
rious memorial, which had been manufactured for the occasion, he would
receive immense eums of money due him, and which were then in the custody
of the Executive, was committed to the institution. As might be supposed,
there was no difficulty in bringing him to this place ; but the disappointment
of the poor, deluded man, can be more easily imagined than described, when
he was told the true purpose for which he had been brought. The effects upon
him were also of a serious nature, causing him to refuse his food for weeks
after his admission, and thereby seriously impairing his health ; while he has
not yet ceased upbraiding us with the charge of illegally detaining him in the
house, and preventing him from obtaining his just rights."

7. The Annual Report of the Regents of the South Carolina State Lunatic
Asylum has for many years included a report from the Physician, Dr. Treze-
vant, and another from the Superintendent, Dr. Parker. In the one now
before us that of the Physician is omitted. Dr. Parker states that " on the'5th
of November (1855), there were in the house 171 patients; received, during
the year, 67 ; making 238. Of this number, 22 have been sent home as cured ;
18 have died, and 11 were removed by their friends ; leaving now (Nov. 5th,
1856), under care, 187 ; 100 males and 87 females."

" The number of male and female patients being about equal last year (85
to 86), the excess of the former at this time may be attributed to the necessity
which was imposed on the Board of Regents, by the over-crowded state of the
female portion of the building, to refuse the admission of females."

In the notice of a former report from this institution, we have mentioned
the conflicting views of the persons connected with it in regard to a proposed
enlargement of the buildings, or the erection of new ones. The Regents now

186

Bibliographical Notices.

[July

advocate the construction of two small buildings, adjacent to the existing
establishment.

In our notice of the report for 1855, from the Bloomingdale Asylum, it was
stated that the organization of the South Carolina Asylum had recently been
changed. It now appears that the change has not yet gone into effect. We
quote the language of the Regents upon the subject : —

" The present organization of our institution is certainly far from perfect ;
and yet the task of remodelling it is by no means so easy as some may imagine.
As long as harmony prevailed among our officers, and a spirit of mutual con-
cession was manifested, its defects were not so apparent; but, during the last
two years, the difficulties arising from this source have increased to such an
extent as to convince us of the necessity of some change. Deeming it wiser,
in the first instance, to attempt an amendment of the existing system, rather
than to adopt one entirely new, the Board has striven so to modify the regula-
tions of the institution as to reconcile the conflicting claims of the chief officers,
and thus retain the services of both. In the hope of accomplishing this end,
the Board suspended the new organization in contemplation at the time of the
preceding report, which would otherwise have gone into operation in February
last, and again undertook to administer the affairs of the institution according
to the system of rules as amended. The experiment has terminated in utter
failure, and we are now fully satisfied — and purpose acting on the conviction —
that harmony cannot be restored except by a radical change of organization."

The result of the experiment was neither more nor less than might have
been expected. There is but one properly efficient organization for an in-
stitution for the insane, and in that the want of harmony among the officers
is very easily remedied. "We allude to that organization in which the Superin-
tendent has the sole administrative control, at the same time that he is the
medical officer in chief. The efforts of the Regents, as described above, were,
at best, similar to those of the tinker who stops the holes of a worn-out pan.
The old pan will soon leak again ; the tinkered organization could not render
satisfactory service, even for one brief year.

In an organization like that of the institution at Columbia, where the Super-
intendent is a Physician, and yet is subordinate, in the treatment of the pa-
tients, to a Visiting Physician, it is next to impossible that justice, in the public
mind, should be rendered to each of these officers. It has been said of such
an organization, that if there be merits, the Visiting Physician gets the credit
of them ; if there be demerits, defects, accidents, the responsibility falls upon
the Superintendent. To a very considerable extent this is true ; and we are
surprised, not that difficulty has arisen between the officers of the Asylum at
Columbia, but, rather, that it did not arise at a much earlier period. It is our
opinion that Dr. Parker must be a pretty good Christian to have remained in
the position which he occupies, as he states that he has remained, upwards of
twenty years.

These remarks are made without the slightest knowledge, upon our part, of
the actual cause or causes of the difficulty between the officers of the Asylum
at Columbia, and with sentiments of high respect for both Dr. Trezevant and
Dr. Parker.

8. The Report from the Indiana Hospital for the Insane informs us that that
institution is "filled to overflowing very much obstructing what is desirable
and necessary to success — a complete classification.

Men.

Women.

Total.
195
171
366
13 L
235
109
17

Patients in the Hospital, Oct. 31, 1855
Admitted in course of the year .
Whole number " . .
Discharged, including deaths
Remaining, Oct. 31, 1856 .
Of those discharged, there were cured
Died

86
174

60
114

53
5

107
85

192
71

121
56
12

1857.]

American Insane Hospital Reports.

187

Died of pulmonary consumption, 4 ; chronic diarrhoea, 2 ; apoplexy, 3 ; tabes
mesenterica, 2 ; suicide, 2 ; hypertrophy of heart, 1 ; traumatic inflammation,
1 ; scirrhus of stomach, 1 ; senile insanity, 1.

Aggregate of patients, in eight years . . 537 543 1080

Recoveries 297 297 594

Deaths ....... 100

Dr. Athon says that he is " pretty well posted as to the number of insane in
the State," and thinks that number " not far short of twelve hundred, or about
one to every thousand inhabitants." " In some localities, such as the older
counties on the Ohio River, and in those counties where there is a concentra-
tion of business by means of railroads, the proportion is much greater."

The Doctor thinks that tobacco has caused more insanity than spirituous
liquors.

It appears that the Legislature of Indiana has adopted a resolution "inquir-
ing the number of insane patients in the Hospital whose parents were con-
nected by the ties of consanguinity." " Although we have no means of learning
the extent of this relationship," continues Dr. A., "as applied to the whole
number of patients who are and have been inmates of this Institution, there is,
in our humble opinion, a sufficient number of known instances to arrest the
attention of the philanthropist, and call into requisition all his arguments to
prevent the intermarriage of cousins." The Doctor believes, however, that
physical defects, "more commonly than mental obliquities, are found in the
offspring of such intermarriages.

9. The published reports of the Illinois State Hospital for the Insane are
issued biennially. The one now under review is the second which has appeared
since Dr. McFarland became connected with the institution.

Patients in hospital, Dec. 1, 1854

Admitted in the course of two years .

Whole number .

Discharged, including deaths

Remaining, Dec. 1, 1856

Of those discharged, there were cured

Died

Men. "Women. Total.

166
302
468
254

94 120 214
118

Causes of Death. — Exhaustion, following " long-continued maniacal excite-
ment," 8 ; " direct exhaustion of acute mania," 5 ; pulmonary consumption, 2 ;
paralysis, 2; typhoid fever, 1; typhoid dysentery, 1; "wild parsnip," taken
into the stomach, 1 ; suicide, 3.

From this long and thoughtfully written report, we proceed to make such
extracts as appear to be the most worthy of attention and of preservation.

Form and Treatment in relation to Cause. — " Nothing can be more elusive
than the attempt to predict what form of mental disease will follow the opera-
tion of any plain given cause ; and when it is considered that hardly a tithe
of the cases submitted to our attention are thus traceable, but that the character
of the individual mind in its sane state, the effect of education, social position
—all that gives or takes away the tone of the physical system, all that reaches
the understanding or acts through the senses — in short, all the accidents of
life combine to make up each case as we find it, we are prepared to regard
every case as a unit, impossible to be considered, analyzed, or treated with any
great reference to its history.

" It would be a plausible supposition, that the treatment of a given case of
insanity should, be adopted with reference to the cause that had called it into
existence. This would be so, if the relations of cause and effect were always
calculable. If the overwhelming enunciations of the theologian always sank
the frenzied hearer into the insanity of hopeless despair ; if the successful
speculator, who^ had clasped fortune at a single bound, was always thrown into
a state of maniacal rapture, or diseased ecstasy, we could predicate, on the
one case, a cheerful and stimulating treatment, and on the other a spare regi-

188

Bibliographical Notices.

[July

men and gravity of scenery and society. Yet the actual fact is frequently the
reverse of what might be expected."

Comparative Power of Causes. — " Another result of continued observation
among the insane is, that special or exciting causes have less weight in the
production of mental disease, in the mass of cases, than such as are predis-
posing or constitutional. What is frequently given, by the unskilled observer,
as the cause of the disease, is merely one of its accidental manifestations."

Insanity, with Dominant Religious Ideas. — " There appears to be two reasons
why the mental manifestations of the insane have so frequently a religious
tinge. One is, that preceding every attack of insanity from constitutional causes
there seems to be a period when most individuals have an indistinct conscious-
ness that something unusual is about to happen. The mind dimly and fear-
fully apprehends the storm that is approaching. Keason, trembling with these
fearful premonitions, seizes for support on that latent religious sentiment which
lies in every human breast, and when the storm really bursts in its fury, this
sentiment remains prominent in all the ruin that follows. Another reason
seems to be that the insane mind has a natural affinity for the unseen and the
mysterious."

Puerperal Insanity. — " The peculiar pathological condition of the system
known among medical men as ' the puerperal state/ has been an extremely
prolific cause of insanity during the period which this report covers. This may
be partly an accident of the time, though we are satisfied that insanity from
causes incident to the child-bearing state, is more frequent in. the circle from
which patients in this institution are derived, than in those contiguous to most
other hospitals whose reports reach us. Marriages entered into before the phy-
sical system has reached its full maturity ; the great dearth of means of suffi-
cient intelligence to render proper assistance at such a critical period ; the
discomforts attending a sparse population ; and the other deprivations of fron-
tier life, are sufficient to account for the prominence of this among the causes
enumerated in our table."

Regimen and Medication. — " The general and local depletions, the counter-
irritants, the spare diet, and the routine once prescribed under the general
phrase of 'the antiphlogistic regimen/ have long since yielded to a method
diametrically opposite. Even cases which bear on their surface the tokens of
sthenic action are now met, with constant success, by a liberal diet and pro-
perly graduated stimulants. We allude to this, because we yet occasionally
receive patients who have, to quote a descriptive letter recently received with
one of them, ' been well bled and blistered, but without apparent effect.' "

True Use of Insane Hospitals. — " An insane hospital bears the same relation
to the diseased mind that the splint and bandage do to the fractured limb. It
protects it from dangerous extraneous influences, and holds it in a position to
admit of the requisite medication. As there are some fractures where neither
of these demands exists, so there are many cases of insanity where nature and
art may effect the cure without unusual interposition. To an insane person
whose domestic attachments remain firm, and whose delusions in no way im-
pair the moral affinity which should exist to those about him, removal to the
care and society of strangers is a measure of, at best, questionable expediency."

Caution against too early removal of persons to the Hospitals. — "Cases of
insanity occurring without known cause, in a neighbourhood and at a time
when fever is epidemic, should be examined with great caution before a tedious
journey to the hospital is resolved on, as that strain on the vital resources is
almost invariably made when the system demands strict quiet in order to pass
the coming crisis of the disease. Especially should such a transference be
avoided when the pulse has become disturbed, the mouth and teeth incrusted
with sordes, and other symptoms of the typhoid state have begun to show them-
selves. A journey under such circumstances is little short of manslaughter."

In all recent cases, " in young persons particularly, some weeks should elapse
before the extreme step (removal to a hospital) is taken. This we urge, still
keeping prominent the fact that insanity is of difficult cure much in proportion
to the length of its continuance."

Causes which are less potent in Europe than in America. — A somewhat pro-

1857.]

American Insane Hospital Reports.

189

tracted discussion upon that numerous class of cases in which the insanity is
the offspring of masturbation, is closed by the following remarks: —

" When the writer of this report attempted to find this class of cases in the
insane hospitals of continental Europe, to his surprise they were almost wholly
wanting; and, although abounding to a greater extent in those of Great Britain,
they were derived from what are there termed ' the lower classes.' The care-
less abandon with which the population of the former yield themselves to the
full enjoyment of the almost innumerable festivals, gives us the key to their
general exemption from those detestable vices which develop themselves where
such enjoyments are proscribed. An observer can find tolerance for the Sab-
bath-crowd of a German beer-garden, in the counter-observation that it keeps
down the population of the lunatic asylum. The race-course, the regatta, the
cricket-ground, and the boxing-club, banish such vices in a great measure from
the wealthier and more educated classes of British society, and confine them
to the sedentary artisan, forced to celibacy by his poverty, and denied the costly
amusements of his richer and more aristocratic neighbour. The careful per-
sistency with which manly sport and exercise is made to blend with English
university life, did not escape the quick observation of our countryman, Irving,
whose baronet, having heard that his son at college had dismissed his tutor
and taken a horse, uttered no reprimand, but doubled his allowance, that he
might afford both.

" So long as we have no national amusements whatever; so long as mirth
and sport are considered exclusively as puerilities; so long as the college is
without its gymnasium and its traditional sports, and the school-house has no
well-trodden play-ground ; so long as man is an iron-bound and close-rivetted
dollar-grinding automaton, which bends every moment at some false shrine of
morality or repectability ; just so long will the wards of American institutions
for the insane be thronged with such subjects as we have described. If society
will constantly wear its Sunday dress of enforced constraint, it must pay for
the privilege in such coin as violated nature chooses to exact/'

10. The reports of the Officers of the Missouri State Lunatic Asylum are
biennial. The one now under notice contains the subjoined statistics : —

Patients in the Asylum, Nov. 27, 1854
Admitted in the course of two years
Whole number ....

Discharged

Remaining, Nov. 24, 1856
Of those discharged, there were cured
Died

Causes of Death. — Consumption, 5; ulceration of the bowels, 4; acute
mania, 3 ; chronic mania, 2 ; epilepsy, 1 ; strangulated hernia, 1 ; pneumonia,
1 ; suicide, 1.

Dr. Smith makes the following remarks upon the registration of deaths: —
" It would seem, in registering the causes of death in hospitals for the insane,
the chief design should be to indicate the mortality of insanity ; but in exam-
ining the tables of different institutions, we would infer the leading object to
be to show the fatality of other forms of disease, and that very few ever die
of this grave malady. Could any one, with all our reports before him, draw
a correct conclusion in regard to the mortality of insanity, or the comparative
mortality of the different forms of the disease ? It strikes me that, in deter-
mining these points, our observations have not been as accurate and discrimi-
nating as they might have been, and as doubtless true, that diseases have not
unfrequently been registered as the causes of death which were clearly the
effects of insanity. It is well known, for example, that in cases of chronic
mania diarrhoea usually precedes death ; indeed, this is so common that it may
with as much propriety be regarded as one of its symptoms, as it is of the last
stage of phthisis ; and yet, almost without exception, this is registered as the
cause of death. In all institutions whose reports indicate the causes of death,
No. LXVIL— July 1857. 13

Men.

Women.

Total.

111

116

205

135

190

Bibliographical Notices.

[July

diarrhoea is given as one of the most prolific, and thus, chronic insanity, in
most instances perhaps the true cause, is left entirely out of view, and the
impression is made that it is rarely attended with fatality."

The subject thus treated by Dr. Smith has undoubtedly arrested the atten-
tion of most physicians engaged in the treatment of the insane. Years ago
we gave to it no inconsiderable study and reflection. It is one of those sub-
jects which are encompassed with difficulties of such a nature that, in the
present state of pathology, the attempt to arrive at scientific truth appears to
be futile. The remarks of Dr. Smith give no clue to any method by which
the difficulty is to be overcome. Indeed he has, himself, like many others be-
fore him, made the mistake of treating as a pathological condition that which
is merely the symptom of a pathological condition, or rather, in the present
state of our knowledge, the symptom of various pathological conditions. If
there be a " mortality of insanity," there is, by parity of facts and by parity
of logic, a mortality of delirium. Supposing, then, that it be recorded in a
given case, that the patient " died of delirium." Of what value in science is
the record ? None. What definite idea is imparted by it? Simply that the
symptom of delirium attended the disease of which the patient died. It is
impossible for the reader to tell whether he died of typhoid fever, or of ery-
sipelas of the head, or of some disease which caused acute mania, or of menin-
gitis, or by starvation, or by exposure to cold, or from the effects of opium,
haschish, or some other narcotic, or from some other of those causes of mor-
tality which are accompanied by delirium. So if, in the report from an insti-
tution for the insane, it be recorded that a patient died of acute mania, the
reader is left in entire uncertainty of the real pathological lesion which termi-
nated life. It might have been meningitis ; it might have been cerebritis ; it
might have been cerebral anaemia, or the condition producing dyspepsia, or
some organic affection of the heart, or the liver, or some one or more of various
other conditions. If it be reported that another patient died of chronic in-
sanity, the reader is no less puzzled ; no less bewildered ; no less confounded.
He gains from it no knowledge which is of any value to him.

From the foregoing considerations, it will be perceived that we cannot agree
with Dr. Smith, when he says " Diseases have not unfrequently been registered
as the causes of death which were clearly the effects of insanity." Make the
sentence read " clearly the effects of that lesion, or of one of those lesions one
symptom of which is insanity," and it would fully coincide with our views of
the subject. The following remark, however, is in accordance with our opin-
ion : " It is impossible for any mind, however acute and penetrating, to deter-
mine the influence of a morbid state of the brain upon the fatality of the
numerous maladies to which the insane are subject."

The subjoined extract places in its true light the subject upon which it
treats : —

" While the law of love is the great distinguishing feature of hospitals for
the insane, I do not wish to be understood as stating that an instance of un-
kind treatment never happens. Examples of this kind will occasionally occur,
with the strictest supervision, as long as imperfections attach to human nature.
I do, however, with confidence state that in a well conducted asylum for the
insane, where a regular system of management pervades the whole building,
and all are alike and daily impressed with the importance of uniform kind-
ness and self-control, in the midst of provocation of every description, such
occurrences are of far less frequency than they would be if the same patients
were in private families, and under the immediate control of their nearest
friends and relations."

11. The report for 1855, of Dr. Reid, the Superintendent of the State Insane
Asylum at Stockton, California, is ornamented with an engraved view of that
institution. The building is of the castellated Gothic order, and, if it looks as
well as its miniature representation, is a handsome edifice.

"The institution possesses an eligible and healthy situation, plain and sub-
stantial buildings; large, airy, and well ventilated rooms; cold, warm, and
shower baths ; ample space for recreation ; and grounds for labour, with plenty
of trees, shade, and pure air.

1857.]

American Insane Hospital Reports.

191

Men.

Women.

Total.

120

134

184

214

304

348

148

168

140

162

"There is not a single cell in or about the establishment; and only ten
rooms with double doors, and strong wooden gratings in the windows.

" The reading-room contains a library of two hundred choice volumes, seven
daily newspapers, eight weeklies, and one monthly.

" The cabinet contains above one hundred species of birds, fifteen species of
animals, and a fine collection of reptiles, shells, and minerals. They are
nearly all of California origin.

" The block of land on which the main buildings are situated, has been laid
out and planted with a great variety of indigenous and exotic trees and shrubs.
The office, apothecary, and reception rooms have been furnished neatly and
elegantly, and all the wards, halls, and rooms supplied with comfortable and
substantial furniture. In fact, the institution is now in an elegant condition,
and will compare favorably with those of a similar character in the Atlantic
States."

Patients in the Asylum, Jan. 1, 1855
Admitted in course of the year
Whole number
Discharged, recovered

Died

Remaining, Dec. 31, 1855

The report contains a brief history of the progress of insanity in California,
and the measures adopted for its treatment. We give a synopsis of the most
valuable portions of it.

In the course of the year 1850, about twenty-two cases of insanity were known
in San Francisco, some of them, as we infer from the report, having been brought
in from the surrounding country. They were treated at the Marine Hospital,
or temporarily confined on board a vessel in the harbour. In 1851, thirty-four
cases were received at the State Hospital in Sacramento, and 13 at the General
Hospital in Stockton. " In 1852, by an Act of the Legislature, all insane per-
sons throughout the State were directed to be sent to the State Hospital, in
Stockton, for treatment. In this year 124 were admitted." " In 1853, the
General Hospital system was abolished, the County Hospital system substituted,
and the Insane Asylum created." That which was the General Hospital, at
Stockton, was now converted into an institution for the insane. In the course
of the year, 160 new cases were admitted. In 1854, there were 202 admissions ;
and in 1855, 214.

Whole number of patients, 1851 to 1855, in-
clusive

Discharged recovered . . . .
Died . . . . .

Causes of Death. — Dysentery, 17; epilepsy, 9; mania-a-potu, 7; typhoid
fever, 7 ; marasmus, 6 ; acute mania, 5 ; phthisis, 4 ; puerperal fever, 3 ; para-
lysis 3 ; ascites, 3 ; meningitis, 2 ; erysipelas, 2 ; laryngitis, 1.

" During the four cold, wet months, more deaths occur than during the entire
dry season of eight months. In the past year, of 18 deaths, 12 occurred during
the rainy season. Of 62 deaths in five years, 40 happened in the rainy, and
22 in the dry season."

Regimen and Treatment. — " Simple but substantial food is generally best for
the insane. No greater error can be committed than placing them on a low
and insufficient diet, or administering active purgatives, or abstracting large
quantities of blood. The insane have rarely too much blood, but it is unequally
distributed. The brain is irritable, but not inflamed. This condition demands
quieting remedies and nourishment, not bleeding and starvation. Narcotics
will quiet and control, depletions aggravate and destroy."

Work by Patients. — "Nearly all the clothing for the men, every article of
wearing apparel for the women, all the mattresses, sheets, pillow-cases, and
spreads, used in the institution have been manufactured by the inmates."

Men.

"Women.

Total.

640

713

436

481

192

Bibliographical Notices.

[July

Popular Psychologic Condition. — " In proportion to the population the number
of insane persons in the State is very large ; and the number now in the asylum
shows how rapidly the disease has increased among a people whose distinct ex-
istence bears only the age of six years.

" It is reasonable to suppose that it will progress more slowly hereafter.
Many causes have been greatly modified : some have nearly ceased. The people
have become more settled and permanent, more moral, more temperate, more
contented, happy, and free from excitement.

" A peculiar mania with a propensity to self-destruction has existed ende-
mically throughout this State during the past two years."

Suggested House of Correction for Inebriates. — " An institution of this cha-
racter, carefully established and under proper management, would prove of
incalculable value to the morals, the habits, and the industry of the people ; it
would be productive of wealth, prosperity, and happiness to thousands of fami-
lies in the land, and a source of revenue and profit to the State. It would pro-
duce more beneficial effects, result in more immediate good and permanent
benefit to the people and the State, than all the Maine liquor laws and statutes
of temperance that were ever enacted."

Meteorological observations for 1855 at the asylum. Latitude 37° 57' N. ;
longitude 121° 14' 26" W.

Mean.
8 A. M. 2 p. M. 8 p. M.

January 44° 54° 47°

February 49 62 54

March 56 65 59

April 58 66 58

May 59 69 61

June 69 83 73

July 70 81 75

August 70 88 74

September .... 62 80 68

October 64 82 70

November 48 57 52

December 43 53 48

January — Rain, 2.9 inches ; cloudy days, 14 ; clear days, 17. February — ■
Rain, 2.74 inches; cloudy days, 7 ; clear days, 21. March — Rain, 2.2 inches ;
clear days, 22; cloudy, 9. April — Rain, 3.29 inches ; clear days, 20; cloudy,
10; on the 11th, heavy hail. May — Rain, 1.1 inches ; clear days, 25 ; cloudy,
6 ; on the 14th, thunder, lightning, and hail. June — Rain, 1 day ; 29 days per-
fectly clear. July — Rain, none ; every day clear. August — No rain nor clouds ;
31 clear days; wind invariably N. W. September — No rain; every day clear;
wind N. W. invariably. October — No rain ; every day clear ; wind N. W.
November — Rain and dew, .74 of an inch ; clear days, 20 ; cloudy, 10. Decern-
jjer — Rain 2.42 inches ; cloudy days, 14 ; clear, 17. P. E.

Temperature.
Maximum.

8 a. m. 2 p. m. 8 p. m.

52°

68°

54°

82"

Minimum.
8 a.m. 2p. m. 8p.m.

36°

44°

42°

Art. XV. — On Dysentery and its Treatment. By Henry Tiedemann, M. D.,
Member of the College of Physicians, and of the Academy of Natural
Sciences at Philadelphia. 12mo. pp. 29. Philadelphia, 1857.

In the publication of this essay the leading object of the author, as set forth
in the preface, is to make known to the profession his method of treating
dysentery, with the view of bringing it into more general use.

In furtherance of this object, Dr. Tiedemann introduces his therapeutical

1857.]

Tiedemann, Dysentery and its Treatment.

193

directions, with some very interesting general remarks on the pathology of
dysentery.

He maintains that the inflammation of the lower portion of the intestinal
canal, in which it is now almost universally admitted that the disease essen-
tially consists, commences invariably by a hypersemic, inflamed, and infiltrated
condition of the submucous intestinal tissue, the inflammation of the proper
mucous membrane, when it occurs, being the result, always, of an extension
to it of the disease previously existing in the subjacent areolar structure. To
this latter he refers the tenesmus, and frequent discharges of a purely mucous
character which constitute the prominent and almost characteristic phenomena
of dysentery, especially in its early stage. As soon as the discharges become
mixed or stained with blood, it is an indication, he remarks, that the inflam-
mation is no longer confined to the submucous, but has extended to the mucous
tissue itself.

Although Dr. T. is probably correct in locating the hyperemia and inflam-
mation, in the early stage of most cases of simple dysentery, in the submucous
areolar structure, yet, as in many endemics the discharges from the very onset
of the attack consist either almost exclusively of blood, or of mucus more or
less mixed with blood, it is evident that from the first the mucous, as well as
the submucous tissue, may be simultaneously inflamed.

The hyperaemia of the capillary system of the rectum, constituting the first
stage of dysentery, Dr. T. refers to a repletion of the large veins of the liver,
and consequent disturbance of the circulation through them.

" The interruption of the venous circulation in the liver, with otherwise
healthy individuals, during summer, "is caused," he remarks, " by increased
venosity. In this season all the tissues of the body, and, in some measure, all
the organs expand, consequently also the liver. This expansion of the liver is
not only owing to the higher temperature, but also to the slower circulation of
the blood in its overcharged veins. The disturbed circulation of the veins of
the liver must necessarily cause a disturbance of circulation in all the veins
of the abdomen, which will extend to the capillary vessels, and under circum-
stances favourable to the disease, may generate the hyperaemia as a precursor
of dysentery."

The principal exciting cause of dysentery, according to Dr. T., is cold, with
its influence upon the tissues and organs.

"The influence," he remarks, "of sudden cold upon the liver must be the
contraction of its tissues ; the effect of this contraction, very often, is only the
frequent status biliosus, an overflowing of bile into the duodenum and the sto-
mach; in a measure the bile, by the contraction of the liver, is pressed out of
the tissues of the liver. This stat. bilios., a frequent attendant on dysentery,
indicates the propriety of administering emetics, which are not applicable in
all cases of dysentery. But the contraction of the liver and of its vessels also
affects the circulation of the blood in the abdominal veins, even to the capil-
laries, and must produce the most injurious effect in that part of the intestines
which is most remote from the liver. This part is the rectum, in which, on
account of its almost perpendicular position in the cavity of the pelvis, the
return of the blood is more difficult, and favours the development of hyperemia
to a still greater extent. This hyperaemia first produces a narrowing of the
intestinal canal, and consequently the sensation of pressure and fulness, as
if the rectum were overcharged with feces. This erroneous impression, by
reflex action, causes an increased urging to stool. Next, the submucous tissue
becomes infiltrated and tumid, and the mucous membrane is excited to an in-
creased secretion. This infiltration presses the mucous membrane of the duct
closely together, the passage is entirely closed, and tenesmus, the first charac-
teristic symptom of dysentery, is the result. A general febrile reaction, gas-
tricism, and other minor or more important symptoms ensue.

" The further extension of dysentery from the rectum into the higher parts
of the intestinal canal, depends upon the mechanical progress of the hyperaemia
into the capillaries, and the infiltration into the submucous tissue, and is ex-
plained by the arrangement of the veins in the duplicatures of the peritoneum.

"During the further course of dysentery, the mucous membrane must ne-

191

Bibliographical Notices.

[July

cessarily become involved in the morbid process ; the deep transverse folds of
the mucous membrane, embedded in the submucous tissue, are always first
affected." " As long as the mucous membrane is not involved in the disease
we find the peculiar dysenteric evacuations which form the second characteristic
symptom of dysentery. When the mucous membrane becomes involved in the
process of the disease, it soon shows its morbid action by the admixture of
blood, generally of a light colour.

" The further course of the disease is in proportion to the progress of the
inflammation of the submucous tissue and the mucous membrane, the forma-
tion of ulcers with undermining passages in the submucous tissue, croup-like
secretions, &c. Pus and ichor are poured out, and not unfrequently typhoid
phenomena appear as an effect of the resorption of these secretions, but not
as constituting a separate species of dysentery."

In its general outlines the pathology of dysentery as laid down by Dr. T.
is perhaps correct. We must protest, however, against the purely mechanical
explanation which he has given of the manner in which the lesions of function
and structure are induced by the operation of the action of the predisposing
and exciting causes of the disease.

That after long-continued exposure to intense heat, especially when combined
with an impure state of atmosphere, the sudden exposure to even a moderately
cold temperature, is capable of giving rise to hyperasmia of the lower por-
tion of the intestinal mucous membrane, and a consequent disturbance of the
normal functions of those parts, so as to endanger the occurrence of profuse
diarrhoea, or even of cholera morbus, is unquestionably true ; under particular
circumstances the hyperasmia may also pass over into inflammation and give
rise to dysentery, is likewise granted ; but we cannot conceive of these series
of morbid phenomena being brought about by a dilatation of vessels or organs
from the effects of heat, succeeded by a contraction, from subsequent exposure
to cold of the same organs.

Dr. Tiedemann denies that dysentery is a malarious disease, or has any
affinity to intermitting fever, though it will often be found to prevail in the
same localities with the latter. " It generally makes its appearance/' he re-
marks, "when, after along continuance of hot and dry weather, the atmosphere
becomes suddenly wet and cold. It is an endemic in such portions of the
tropics as have, from the influence of the sea-breezes, the nights much cooler
than the day." All this is certainly correct; dysentery, nevertheless, is known
occasionally to prevail as an unquestionable epidemic, and in sections of
country in which it is otherwise seldom met with ; it is, therefore, very evident
that there are certain unappreciable morbific conditions of the atmosphere
capable of giving rise to it, independent of a mere change in its temperature
and hygrometric condition, although to these latter its production is referable
in the majority of instances.

" I know only of two symptoms which are characteristic of dysentery, and
which always suffice to recognize the disease. The first is tenesmus, the second
the evacuations. These symptoms must occur together to establish a case of
dysentery. Tenesmus, without the characteristic evacuations, constitutes no
more dysentery than the characteristic evacuations without tenesmus would
entitle the disease to be called dysentery. In the different stages of the dis-
ease the tenesmus also assumes a different character; thus —

" In the first stage, it is seldom intermittent, not even in the mild eases ; it
is only more bearable. In the more violent, as well extensive as intensive
cases, the tenesmus is exciting in the highest degree, and truly torturing, and
the discharge of inodorous mucus, mixed with white spheroid granules, with
or without blood, gives no relief. As soon as the tenesmus becomes distinctly
intermittent, the disease is either on the decline, or it has entered on the

" Second stage. The tenesmus is now accompanied by a high state of anxiety,
not by excitement, as in the first stage. Every evacuation is followed by great
exhaustion and violent burning in the rectum, from the anus upwards, whilst
tenesmus comes and goes with distinct intermissions.

"In the third stage the intermissions are of longer duration; the tenesmus is

1857.]

Tiedemaon, Dysentery and its Treatment.

195

preceded by greater anxiety, and the evacuations by prostration, even to faint-
ing. The burning sensation in the anus and rectum diminishes.

" These three stages do not always appear in this pure and decided form, as
the three stages are sometimes or generally found in different parts of the in-
testines.

" The symptoms of tenesmus are explained by the anatomical results of the
three stages.

" In the 1st stage inflammation and a spongy condition of the submucous tis-
sue. Discharge: mucus, with or without blood, and occasionally with balls of
scybalse.

"In the 2d stage, decided sympathy of the mucous membrane and commence-
ment of ulceration. Discharge : shreds of the lining membrane of the intes-
tines ; brownish mucus, more liquid, and coloured with blood, rarely mixed
with pure blood.

"In the 3d stage, extension and deep ulceration of the mucous membrane
and undermining ulceration of the submucous tissue. Discharge: blood mixed
with pus, shreds of necrotic cellular tissue, and ichor.

" The evacuations, however, do not always correspond with that described in
each of the three stages ; and not unfrequently we find, in one evacuation, the
discharges belonging to two or three stages at the same time ; as all the stages
can exist at once in different portions of the diseased intestines.

"Tenesmus is caused by the infiltration of the submucous tissue, which, by
its swelling, mechanically narrows the passage of the intestines. In the begin-
ning of the disease this swelling causes irritation and contraction of the mus-
cular tissue, whereby the intestinal tube is still further narrowed, so that, in
the progress of the disease, paralysis of the muscular tissue of the intestines,
principally of the rectum, may supervene. The infiltration of the submucous
tissue, which appears in mammillated (hump-like) protuberances on the mucous
membrane, mostly in the direction of the transverse folds, causes the parietes
of the intestinal tube to swell in such a manner against one another that they
come into the closest contact, and that the passage is completely shut up. This
closely compressed mucous membrane causes great urgency to evacuate, as if
the rectum were filled with feces, which by contraction, a real reflex motion, it
were striving to remove. The consequence of these efforts are tenesmus and
the peculiar dysenteric evacuations. "

Dr. T., in his account of the production of tenesmus, seems to have entirely
lost sight of the increased irritability of the mucous tissue of the inflamed in-
testine, which would appear to us to have as much to do with the production of
these as the cause pointed out above.

" The prolapsus of the mucous membrane of the rectum," Dr. T. observes,
" or of a part of the entire rectum, is said to be occasioned by violent contrac-
tions of the muscular tissue of the rectum, also by too violent contraction of the
sphincter. The contraction of the muscular tissue can only produce prolapsus,
when there is, at the same time, relaxation of the sphincter, the violent con-
traction of these muscles must, of course, prevent prolapsus. Prolapsus recti,
however, seldom occurs in the commencement of this disease, and only when
the patient is weakly, and the inflammatory irritation of the muscular tissue
of the intestines passes rapidly over into paralysis, which is communicated
to the sphincter. In very violent or badly treated cases, with persons who
are not otherwise weakly, an early paralysis of the muscular tissue of the
intestines, and of the sphincter, may cause prolapsus recti, a symptom which
always indicates danger. Generally, however, the prolapsus appears in a
more advanced stage of the disease, when the inflammation cannot be
abated, or when it changes to paralysis by the partial destruction of the mus-
cular tissue and extends to the sphincter. This prolapsus does not unfre-
quently occur before death. In all cases of violent dysentery I found, on
examination of the anus, which, at the beginning of the disease had been firmly
closed and red, the same more or less opened, so that the tumid and highly
reddened mucous membrane of the rectum could be seen. At the same time,
the most violent tenesmus continued. This shows, conclusively, that the pro-
lapsus recti is not caused by the spasmodic contraction of the sphincter."

196

Bibliographical Notices.

[July

Having thus presented his views in relation to the pathology of dysentery,
Br. T. gives a general outline of the plan of treatment pursued by him, and
by the employment of which, during the last six years, he has succeeded in
curing upwards of three hundred cases of dysentery, not a single death from
the disease occurring in his practice during that period.

" As dysentery/' he remarks, " in the first two stages, is a hypersemia of the
capillaries of the rectum and colon, and seldom of other parts of the intestinal
tube, induced by the disturbed hepatic venous circulation, followed by infiltra-
tion and inflammation of the submucous tissue, which in the further pro-
gress is communicated to the mucous membrane and changes to ulceration, it
distinctly indicates in these two first stages a general and local antiphlogistic
treatment.

" The internal remedy which I have almost exclusively prescribed, and fre-
quently with surprising success, is nitrate of potassium (kal. nitr.). I have
given it in large doses, which agreed perfectly well with the patients. Locally,
I have ordered, immediately after each evacuation, no matter how often they
occurred, injections of pure cold water. (In very severe cases, particularly in
hot weather, he has ordered injections of ice water with the best effects.) As
diet, I ordered milk, gruel, barley, rice-water, toast and water, pure water, and
buttermilk as much as the patient liked to take.

" The nitrate of potassium and the injections, I continued until the tenesmus
had ceased, which, in the majority of cases, happened in from six to twelve
hours. As the tenesmus diminished, the mucous and bloody evacuations also
diminished, and when it ceased, they generally disappeared entirely.

" Before I order the nitre, I consider the state of the digestive organs : which
either require an emetic or purgative, or are in such a condition that nitre can
be immediately given. If during the treatment with nitre and injections of
cold water, evacuations of fecal matter do not occur, at least once in twelve
hours, which usually is the case, I recommend a corresponding dose of castor
til."

Under all circumstances, and in every case of dysentery, whether sporadic,
endemic, or epidemic, whatever may be the age, sex, or constitution of the
patient, Dr. T. has found the above treatment applicable.

When the dysenteric symptoms, with all symptoms of fever, are subdued ;
the evacuations having become natural, which he has often found to occur
within twelve hours, Dr. T. gives a solution of sulphate of quinine, and, on the
third day frequently allows a better diet ; after each evacuation he directs an
injection of cold water for a few days longer. If regular evacuations do not
occur he orders occasional doses of castor oil.

In the first two stages of dysentery, Dr. T. denounces all other remedies as
useless, if not mischievous. In only two severe cases occurring in sensitive
females, was he obliged to administer narcotics. "When the skin is inactive he
gives the nitre dissolved in an infusion of ipecacuanha, with the addition some-
times of camphor-water.

"Under this treatment," Dr. T. remarks, "when I was called in time, the
disease seldom reached the second stage, never the third ; the patient recovered
very fast, probably because the disease was not of long duration. I have had
but few cases where it lasted longer than seven days ; only one lady was ill to
the fourteenth day, although the dysenteric symptoms had eeased on the seventh
day; she was pregnant on the second month, but did not miscarry. Most
cases had already changed so favourably on the third day, all the dysenteric
symptoms having ceased, that no more medicine was required, and I could
leave the patient, merely ordering a proper diet for a short time to come."

When the disease has been allowed to run on to the third stage, with a con-
tinuance of the injections of cold water, Dr. T. directs quinine, tannin, acetate
of lead, &c, generally with opium, accordingly as the case seemed to require
the one or the other remedy; with daily doses of castor oil, to promote the
necessary evacuations, and, in time, a nourishing diet.

Of the treatment of dysentery, in its early stages, exclusively by nitre and
injections of cold water we have no experience. The professional standing of
Dr. T. is such, however, as to press it strongly upon our attention. We have

1857.] Todd, Diseases of the Urinary Organs, and on Dropsies. 197

prescribed the nitre, occasionally, in conjunction with opium and ipecacuanha,
and we are persuaded with the best effects. We cannot agree with Dr. T. in
his denunciation of opium as positively mischievous in the early stages of
dysentery. We are in the constant habit of giving it from the very onset of
the disease, and always with the very best effect. To derive from it the good
it is calculated to produce in this disease, it must, however, be given in large
doses. The effect of small and frequently repeated doses is rather mischievous
than beneficial. Although we have generally found sporadic dysentery a trou-
blesome and obstinate rather than a fatal disease, we have certainly not been
quite so successful in its treatment as Dr. T. In a few cases, occurring in very
young, or in diseased and broken down constitutions, the disease has termi-
nated fatally. We very much doubt whether in these cases the termination
would have been different had we subjected them to the treatment laid down
in the essay before us. D. F. C.

Art. XVI. — Clinical Lectures on Certain Diseases of the Urinary Organs, and
on Dropsies. By Robert Bentley Todd, M. D., F. R. S., Physician to King's
College Hospital. 8vo. pp. 283. Philadelphia: Blanchard & Lea, 1857.

The plan of this volume is similar to that of the recent work by the same
author, on Diseases Affecting the Nervous System. The favourable reception
given to the latter has led to the publication of these lectures. So the author
says in his preface; and we are glad to see this statement, not merely from a
disposition to congratulate him on the satisfaction which he must derive from
the evidence that his labours are approved by his professional brethren, but
because the fact denotes a disposition, on the part of the medical public, to
receive with favour works of a practical character, like those for which we are
indebted to Dr. Todd. Believing, as we do, that the advancement of practical
medicine is to be promoted mainly by clinical researches, aided by the light de-
rived from the investigations of the anatomist, the physiologist, and the chemist,
we regard the avidity with which such works are sought after as indicating a
prevailing tone and spirit productive of present benefit, and promising much
for the future. Medical instruction of late years has been characterized by
the prominence given to bedside teaching; in other words, medicine, as a
branch of instruction, like other branches of scientific knowledge, is considered
as demanding illustration and demonstration, which, of course, can only be
afforded by placing before the eyes of students patients exemplifying the phe-
nomena of disease. So in medical literature, the works considered most useful
to the practitioner are those which embody the facts obtained by clinical obser-
vation or the results deduced therefrom.

But clinical teaching, oral or bibliographical, is not so simple and easy a
matter as some imagine. The mere rehearsal or description of the obvious
phenomena of disease is barren and tedious. Dry reports of cases, if read at
all, are read with little profit, and a considerable portion of the periodical medi-
cal literature of the present time is of this description. To excite interest and
furnish instruction, the historical facts of disease are to be employed as exem-
plifying truths underlying the mere external phenomena — truths having direct
and important bearings on diagnosis, pathology, and therapeutics. In a word,
what the medical student and practitioner desire to know is, not alone that
which is to be observed in the progress of diseases, but the significance of that
which observation discloses.

Returning to the volume which has suggested these remarks, we have a series
of sixteen clinical lectures on certain diseases of the urinary organs, and on
dropsies. The object of the author is to present the most important of the
practical points pertaining to our present knowledge of these diseases, as illus-
trated by cases selected from those occurring under his observation at King's
College Hospital. The histories of the cases are given with sufficient detail
for illustration, avoiding tedious and useless minuteness. They are selected

198

Bibliographical Notices.

[July

judiciously with reference to their pertinency in exemplifying points of diag-
nosis, pathology, and therapeutics. The two first lectures are devoted to
hematuria ; lectures third and fourth, to the various forms of disease of the
kidneys associated with albuminous urine and dropsy. Dropsy dependent on
renal disease is treated in lectures fifth, sixth, seventh, and eighth. Lectures
ninth and tenth are appropriated to cardiac dropsy. Ascites is the subject of
the eleventh lecture. Morbid conditions of the kidney, attributed by the author
to gout, form the subject of the twelfth lecture. Purulent urine and its rela-
tions are treated of in lecture thirteenth. In the remaining three lectures,
gout is considered in its various pathological relations.

The reader will perceive from the foregoing enumeration that the topics
discussed in these lectures cover considerable ground. The scope of the work,
in fact, would hardly be inferred from the title. The propriety of including
gout (to which not a small space is allotted) among diseases of the kidney, is
open to criticism ; but it must be admitted that it would be difficult to fix upon
a nosological place more appropriate. Were we to write a review of the work,
we should find an occasion for criticism in the pathological relations assumed
to exist between affections of the kidney and bladder and the gouty diathesis.
The tendency to refer a great variety of local affections to this diathesis, on
grounds which will not bear critical analysis, is not peculiar to the author, but
is a habit with British writers. One reason for this doubtless is, that gout is
much more prevalent in Great Britain than in this country, or on the continent
of Europe.

On the whole, a careful perusal of this work has afforded us pleasure and
profit. The subjects are among the most interesting and important of those
pertaining to practical medicine. The author's views are consistent with the
developments resulting from the investigations of late years, directed toward
the diseases of the kidneys and their pathological relations. The manner in
which the subjects are treated is well adapted to meet the wishes of most prac-
titioners in obtaining a practical work. The points are clearly and concisely
presented in a simple colloquial style of composition. We commend the volume
most cordially to our medical brethren. A. F.

Art. XVII. — On the Diseases of Women, including those of Pregnancy and Child-
bed. By Fleetwood Churchill, M. D., T. C. D., M. R. I. A., etc. etc. A new
American edition, revised by the Author. With notes and additions by D.
Francis Condie, M. D., etc. etc. 8vo. pp. 768. Philadelphia : Blanchard &
Lea, 1857.

The treatise of Dr. Churchill on the Diseases of Women, which has already
passed through numerous editions, is too well known to the profession at large
to require that we should, at the present time, enter into a formal examination
of the manner in which the author has accomplished the task undertaken by
him in the preparation of the work — to present, namely, a faithful guide to the
advanced student and young practitioner in the investigation of the pathology
and therapeutics of the maladies incident to woman, during the non-pregnant
condition, as well as during gestation, and the puerperal state.

His description of the several diseases included within the scope of the
treatise, are recognized as clear, accurate, and satisfactory, and his pathological
views as in accordance with the observations of the latest and most reliable
authorities, while his practical directions, based upon the experience of those
skilful in the treatment of female diseases, compared and tested by the results
of his own ample practice, are sound and judicious — neither marked by undue
timidity on the one hand, or that indiscriminate rashness which has, too often,
been mistaken for masterly boldness, on the other.

In the edition before us, the work has undergone a thorough revision at the
hands of the author ; a considerable portion of it has been rewritten, and much

1857.]

Churchill, Diseases of Women.

199

new matter has been added throughout. It comprises, unquestionably, one of
the most exact and comprehensive expositions of the present state of medical
knowledge in respect to the diseases of women, that has yet been published.

The practitioner may consult it, in full confidence of meeting with a notice
of every valuable contribution towards the elucidation of the nature, character,
and treatment of those affections, furnished by the masters in the profession
who have, of late years, studied them with the closest attention, and under the
most favourable circumstances.

What renders the treatise of Dr. Churchill a safe work of reference for the
young practitioner, is the entire freedom from dogmatism evinced by the
author, or any attempt to bend acknowledged facts in support of his own
opinions, in respect to either the pathological character or therapeutical man-
agement of particular diseases, or to ignore entirely those of too unpliant a
nature to be thus disposed of. In more than one instance, we find that Dr.
Churchill has been induced to modify materially the views previously advanced
by him, in conformity with the teachings of more recent, extended, and accu-
rate observations.

On a reference to the chapter on puerperal fever, it will be perceived that the
author has considered it necessary to change in some measure his views in re-
gard to the pathology of that important and heretofore greatly misunderstood
disease since the appearance of his former edition.

While he still adheres to the somewhat awkward and artificial division of the
fever into distinct species, according as local inflammation predominates in the
peritoneum, in the womb, and in its appendages, or in the uterine veins or
lymphatics, he nevertheless very freely admits that this division is far from
being accurate, inasmuch as cases are seldom met with in which puerperal
fever can be, in fact, described as simple peritonitis, metritis, phlebitis, etc. ;
several or all of these lesions being most usually combined in the same case.
Hence he does not present the several varieties of puerperal fever described by
him as "essentially and widely distinct, as to symptoms, causes, and course, in
every epidemic."

In addition to those forms of the disease delineated by him in former edi-
tions, he adds another, the gastro-enteric, a form under which puerperal fever
unquestionably presents itself occasionally, and which, in its course and termi-
nation, is far less severe and fatal than that under which it usually occurs.
The very excellent description given of it by Dr. C. will prove highly interest-
ing to the practitioner, inasmuch as gastro-enteric or strictly typhoid puerperal
fever has been known to prevail epidemically more frequently than it does as
aD endemic.

To the malignant form of puerperal fever a much greater degree of promi-
nence is given in the present than in former editions, and very properly, it
being confessedly the one that has been most usually observed during the more
recent epidemical visitations of the disease.

While Dr. C. admits that cases of simple peritonitis, metritis, or phlebitis,
etc., may and do occasionally occur during the puerperal state, he nevertheless
very " honestly and candidly" confesses that a more extended experience has
led him "to believe that malignant puerperal fever is something more than a
local affection, and that the constitutional disease is often rather primary than
secondary."

" If any one," he remarks, " will carefully compare a case of simple inflam-
mation of the womb or peritoneum in childbed with a case of malignant epi-
demic puerperal fever, their symptoms, general and local characteristics, course,
and the effects of remedies, they will be obliged to come to the conclusion that,
although the latter may exhibit local disease, it is not exclusively nor primarily
a local affection.

" I should wish to speak very cautiously and guardedly on so difficult a sub-
ject, but, after a careful comparison of the experience of others with my own,
I am inclined to believe that the essential difference between epidemic puerperal
fever and simple inflammation consists in a morbid deterioration of the blood
in the first case, which is rarely present in the latter, or not until an advanced

200

Bibliographical Notices.

[July

stage, whether this deprivation results from some noxious influence, or from
some malign peculiarity of the constitution."

This conclusion Dr. C. founds, among other circumstances, on the particular
season of the year, and the condition of the atmosphere, during which puerperal
fever is found most commonly to prevail, in conjunction, often, with and under
similar circumstances as erysipelas and typhus fever.

" We find," to use his words, " that the same seasons give rise to erysipelas,
typhus fever, and puerperal fever ; that they prevail epidemically at the same
time, and, as an epidemic, take on the same type, and appear capable the one
of giving rise to the other, or of coexisting in the same patient. Further, that
the symptoms of certain forms, at least, of puerperal fever are similar to those
which occur after great surgical operations, and that the secondary lesions are
similar. Now, in erysipelas, typhus fever, and the secondary fever after ope-
rations, there can be little doubt of the depraved condition of the blood, and it
is highly probable that their low typhous character is owing to this blood-poi-
soning. I think, therefore, the conclusion that the peculiar character and ma-
lignancy of certain epidemics of puerperal fever also depend upon a morbid
condition of the blood, however produced, in addition to the local disease, is
evident."

" Whatever," he adds, further on, " that which we call epidemic influence
may be, there can be no doubt that to it the majority of cases of puerperal fever
are attributable, especially the worst and most fatal."

On the subject of the contagious or infectious character of puerperal fever,
Dr. C. presents his opinion thus: —

"After a close and careful examination of the history of epidemics, of cases
recorded, and of the opinions of men of the greatest experience, I believe that
the weight of evidence is in favour of puerperal fever being infectious and con-
tagious, i. e. that it may be communicated from a patient labouring under it to
another who is in contact or close neighbourhood with the affected party."

" It seems impossible to doubt, also, that contagious matter, capable of ex-
citing puerperal fever, may possibly be conveyed by a third party unaffected
by it ; for example, in the cases on record of puerperal fever following the ser-
vices of medical men and nurses who were in attendance upon erysipelas im-
mediately before. The instances are too remarkable, and too numerous, to be
regarded as coincidences, nor would even the prevalence of an epidemic of
puerperal fever at the time invalidate our conclusion ; it might, certainly, render
the cause more influential."

The additional chapters embraced in the present edition, on tetanus, as an
attendant on childbed, on paralysis occurring during gestation and childbed,
and on arterial obstruction in puerperal women, the practitioner will find emi-
nently instructive.

In the one on paralysis are comprised all the facts at present known in refer-
ence to the subject, collected with much care from the few observations that
have been recorded, in which it is expressly noticed, but chiefly from the author's
own experience, and from communications furnished him by his professional
friends.

The general conclusions deducible from the facts thus obtained are : —

" 1. That hemiplegia, paraplegia, or partial paralysis, may occur previous

to, during, or some time after labour.

"2. That by some authors the paralysis, in paraplegia especially, is attributed

to pressure upon the nerves or muscles in prolonged labour ; but this is also

denied, as the same disease follows easy labour, or occurs after the lapse of

some days.

"3. Paralysis may terminate convulsions, or accompany them.
"4. Paralysis may be the consequence of organic disease, or of effusion into
or upon the brain or spinal marrow.

"5. Paralysis may result from reflex action.

" 6. The palsy may depend upon temporary causes, and, among such causes,
albuminaria may be included.

" 7. Hemiplegia may run on into apoplexy, or it may pass off in a few weeks,
or sometimes more slowly. Paraplegia may leave a temporary or more perma-

1857.] Otto, Detection of Poisons hy Medico- Chemical Analysis. 201

nent lameness ; the local paralyses (amaurosis, deafness, etc.) generally last
but a moderate time.

" 8. A nervous or hysterical paralysis may occur occasionally in the unim-
pregnated state, or during pregnancy, but that it seldom continues after de-
livery."

Taken as a whole, we can most confidently recommend the present edition
of Dr. C, in the words of the American editor, as "a complete and faithful
exponent of the present state of medical opinion and experience in reference
to the pathology and therapeutics of the entire range of diseases to which the
female sex is liable, including those of pregnancy and childbed."

Art. XVIII. — Manual of Physiology. By "Williah Senhouse Kirkes, M. D.,
etc. etc. A New and Revised American, from the last London Edition.
With two hundred illustrations. 12mo., pp. 584. Philadelphia: Blanchard
& Lea, 1857.

This manual will long remain a favourite one. It presents precisely such an
outline of the facts and generally admitted principles of physiology as is
adapted to the wants of those who have just entered upon the study of the
science, and that may be conveniently consulted by them during their attend-
ance upon lectures, as well as by those who are preparing for examination, to
recall knowledge already acquired, and to correct any misconceptions into which
perchance they may have fallen.

The outline presented by Dr. Kirkes is that only of physiology, strictly
speaking. Only so much of anatomy, chemistry, and the other sciences allied
to physiology, are introduced as could not conveniently be omitted, without
rendering the account of many important points obscure and defective. All
discussion of unsettled questions, and statements of the conflicting opinions
entertained in regard to them by different eminent observers, are omitted.
Ample references, however, are given to the sources from whence a knowledge
of these may be derived, as well as to those works by the aid of which the
study of physiology in its widest extent may be pursued.

The volume is beautifully and copiously illustrated, and in a manner well
calculated to enlist the eye in the task of conveying to the mind accurate con-
ceptions of much that would be otherwise obscure, if not unintelligible, espe-
cially to the younger student.

In the present edition, by a careful revision, and such additions and altera-
tions as were found necessary, the work is brought up fully to the present date,
so as to present a faithful outline of the received facts and doctrines of physi-
ology. D. F. C.

Art. XIX. — A Manual of the Detection of Poisons hy Medico- Chemical Ana-
lysis. By Dr. Fr. Jul. Otto, Professor of Chemistry in Caroline College,
Brunswick. Translated from the German by Wm. Elderhorsz, M. D., Pro-
fessor of Chemistry in the Rensselaer Polytechnic Institute, Troy, N. Y.
12mo., pp. 178. New York, 1857.

This manual is intended as an assistant for those chemists who prefer work-
ing by rule, and for such as may not be considered as experts, but who never-
theless, by knowledge and practice in manipulation, are qualified to take charge
of medico-legal examinations in cases of supposed poisoning. The author is
known to chemists by a good manual of chemistry which has passed through
several editions in German. The work before us will be found useful in afford-

202

Bibliogratph real Notices.

[July

ing, in a small space, very full and clear details of the methods to be employed
not only in investigations where the nature and kind of poisons are indicated
by the concurrent symptoms, but likewise in those in which such information
is not available as a guide to research. The poisons of a mineral character are
first noticed, and occupy the main portion of the Manual, and of these, arsenic
and its preparations demand and receive the greatest share. This, either as
fly-stone or arsenious acid, is the most common substance, which, either by
accident or design, is the most frequent cause of violent death, since its taste-
less character gives rise to no suspicion until its effects are felt; and the symp-
toms produced are, apart from their sudden accession, so similar as to be mis-
taken for diseases of the same parts, and hence is the most likely case to come
under observation. There was a time in which arsenious acid could be given
so as to produce slow and lingering disease and death, and yet the cause
remain concealed from the imperfections of the analytic methods of those times.
At present it would be futile for any to attempt this, and hope that the cause
should escape detection, except where suspicion could be entirely allayed or
evaded. The present methods of examination are improved to such an extent,
and the organs in which the poison locates itself, and becomes for a time de-
tained in the system, so well ascertained, that its detection is one of the most
certain problems of analytic research. The different methods of procedure are
clearly and methodically stated, and much stress laid on the necessity of absolute
purity in all of the chemical substances used, instructions being given as to the
modes by which certainty on this point may be attained. A variety of the best
methods of examination are given in detail by which the corpus~delicti in its
metallic state may be produced — Marsh, Fresenius, Babo, Wohler, Yon Sie-
bold, Otto, Dunty, Duglos, Hirsch, Graham, Danger, Flanden, Rose, Berselius,
&c. The whole is concluded by some observations on the doubts which may
be raised when the hydrated sesquioxide of iron has been used as an antidote,
and the steps to be taken to clear them up by an examination of the antidote
itself.

Antimony, tin, lead, copper, zinc, and mercury are also noticed in a similar
manner ; the space allotted being in proportion to their importance.

Of the poisons derived from the organic kingdom, strychnia has latterly
attracted most attention, its activity in small quantities having led, notwith-
standing its intense bitterness, to its more frequent use with nefarious intents.
The use of this class for poisonous purposes, except in cases of suicide, is com-
paratively rare ; nevertheless, cases may arise in which it may be of legal
moment to decide this point. Here the Manual gives an account of such as
can be recognized by appropriate tests, and then enters into a detailed account
of the methods applicable to the detection of them, whether volatile or fixed,
the process of Stas being preferred and given in detail. The disadvantages
arising from the use of acetate of lead and animal carbon are pointed out,
and in this connection the application of the latter by Graham and Hoffman
to the elimination of strychnia, noticed. The methodical arrangement of the
subject, and the clear and connected method in which the details are laid
down, recommend the work to the attention of those engaged in medico-legal
research, as it is in these particulars well adapted not only to those for whose
use it is particularly intended, but also as a remembrancer for the more expe-
rienced chemist.

The translator has added to the value of the Manual by the introduction of
matters of importance which had been either overlooked, or for some reason
omitted by the author. He has given a faithful transcript of the original,
although in two or three instances some little obscurity appears in too closely
following the idiom of the original. The mechanical execution, both as to
paper and type, are of a favourable character. R. B.

1857.]

203

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES

IN THE

MEDICAL SCIENCES.

ANATOMY AND PHYSIOLOGY.

1. On the Physiological Mechanism of the Formation of Sugar in the Liver. —
At the session of the French Academy of Sciences, held in September, 1855,
M. Cl. Bernard read a memoir in which, from a variety of experiments de-
tailed, he arrived at the conclusion that sugar, contrary to the views previously
advanced, was not directly generated in the liver at the expense of one or other
of the elements of the blood, but was produced always by the fermentation of a
special substance previously formed.

At the session of 23d March, 1857, M. Bernard announced that the foregoing
views had been fully verified by subsequent experiments, and that he had suc-
ceeded in isolating the glycogenic matter which precedes the formation of sugar
in the liver.

The glycogenic hepatic matter he describes as possessing characters which
render it altogether analogous to hydrated starch which has already experienced
a commencing change. It is a neuter substance, without smell or taste, com-
municating to the tongue the same sensation as starch. It is soluble, or per-
haps more correctly speaking, suspensible in water, to which it communicates
a deep opaline tint. It presents nothing characteristic under the microscope.
Iodine develops in it a color varying from a deep violet blue to a clear mar-
roon red, rarely a decided blue. When heated to redness with lime, no ammo-
nia is disengaged, which indicates the non-existence in it of azote. It does not
reduce the salts of copper dissolved in potash ; it does not undergo the alcoholic
fermentation by the addition of yeast; it is entirely insoluble in strong alcohol,
and is precipitated from its aqueous solution by the subacetate of lead, animal
charcoal, etc.

It is in its conversion into sugar that the analogy of the glycogenic matter
to hydrated starch is most clearly shown. All these influences, without excep-
tion, which transform vegetable starch into dextrine and glycose, are capable
also of changing the glycogenic matter of the liver into sugar, in passing
through an intermediate condition analogous to that of dextrine. Thus pro-
longed ebullition in diluted mineral acids, the action of vegetable diastase,
and that of all the analogous vegetable ferments, such as the juice or tissue
of the pancreas, the saliva, the blood, etc., readily transform the glycogenic
substance into sugar. As this change gradually takes place, the solution of
the glycogenic matter loses gradually its opalescence, and also its property
of being coloured by iodine. So soon as it has undergone the saccharine trans-
formation, it acquires the power of reducing the salts of copper dissolved in
potash, of undergoing the alcoholic fermentation and disengaging carbonic
acid upon the addition of yeast. The aqueous solution of the hepatic glyco-
genic matter does not become changed spontaneously into sugar; when left

204

Progress of the Medical Sciences.

to itself it is very slow in undergoing any change, and resists to a certain extent
the putrefaction of the cooked tissue of the liver.

■ Torrefaction, the limited action of ferments, and of the mineral acids, change
the glycogenic matter into a substance with characters altogether similar to
those of dextrine.

From the several experiments conducted by M. Bernard, it is clearly esta-
blished that the liver of dogs nourished exclusively upon flesh possesses the
special property, enjoyed by no other organ of the body, of generating a glyco-
genic matter analogous to vegetable starch, and, like it, capable of becoming
changed into sugar in passing through an intermediate state like dextrine.
Hence, the formation of sugar in the liver is the result of the succession and
connection of two acts essentially distinct. The first, exclusively vital, con-
sists in the creation of the glycogenic matter in the living hepatic tissue.
The second, purely chemical, consists in the transformation of the glycogenic
matter into sugar by the aid of a ferment.

M. Bernard considers the manner in which the contact between the glyco-
genic matter and its ferment takes place in the living body. He found that the
fluid blood possesses the property of changing the glycogenic matter, with great
promptitude, into sugar; and this he believes to constitute in the liver the sole
ferment. Without entering into the intimate mechanism of the contact be-
tween it and the glycogenic material as formed, and the explanation of the
physiological causes by which it is varied in activity, M. Bernard simply re-
marks, that the phenomena of the living organism show, besides the slow and
nutritive circulation of the liver, that there is another, intermittent, variable,
and the suractivity of which coincides with the appearance of an increased
quantity of sugar in the tissue of the organ.

In animals, during digestion, he remarks, the circulation in the vena portae
is surexcited, and then the transformation of the glycogenic matter is much
more active, although the formation of this matter does not appear to corre-
spond to this period. The same suractivity of the circulation may be aroused
in the interval of digestion, and then the transformation of the matter into
sugar takes place in like manner.

In hibernating or benumbed animals, as frogs, for instance, the relaxation
of the circulation caused by the diminution of temperature, causes a diminu-
tion and sometimes a complete disappearance of sugar in the liver. The gly-
cogenic matter, however, it can be shown nevertheless exists there. It is only
necessary to arouse the circulation of the benumbed frog by the application of
heat, to cause the sugar to reappear in the liver. Reduce the temperature and
it again diminishes or disappears, to again reappear upon subjecting the ani-
mal to the influence of an increased temperature. And this alternation, by the
same means, may be repeatedly brought about without giving the animal any
food.

In hot-blooded animals we can produce similar variations in the production
of sugar by the liver by acting upon the abdominal circulation through the
nervous system. M. Bernard has shown that when the spinal marrow is
wounded or divided below the origin of the phrenic nerves, the activity of the
hepatic circulation is considerably diminished, so that, after four or five hours,
there are no longer any traces of sugar in the liver of the animal, though its
tissue still remains charged with glycogenic matter. He has also proved that,
in wounding the cerebro-spinal axis in the region of the fourth ventricle, phe-
nomena directly the opposite are produced, the abdominal circulation is very
much accelerated, and, in consequence, the renewed contact of the glycogenic
matter with its ferment considerably extended, and hence the transformation of
the matter becomes so active, and the quantity of sugar carried into the blood
so considerable, that the animal becomes diabetic, in other words, the excess of
sugar poured into the blood by the surexcited liver passes into the urine.

Under the two conditions referred to, the nervous system acts evidently upon
the purely chemical manifestation of a physiological phenomena. But when we
analvze its mode of action, we recognize that the effects are only mechanical,
and were directed, in the first place, upon the motor organs of the capillary
circulation, and have effected sometimes the diminution or suspension, at others

1857.]

Anatomy and Physiology.

205

the augmentation or extension of the contact of the two substances capable of
reacting the one upon the other. Giving birth thus to a chemical phenomenon
which the nervous system rules indirectly, but upon which it has no direct or
primitive action.

" With respect to the conclusions that we are enabled to deduce, in reference
to general physiology, from the mechanism thus indicated, in respect to the
formation of sugar in the liver, we cannot but be struck with the similarity
which exists, in this respect, between the glycogenic function of the liver, and
the production of sugar in certain acts of the vegetable organism. In a seed,
for example, which produces sugar during its germination, there occur equally
two distinct series of phenomena ; the one primary and entirely vital, is the
formation of starch under the influence of the life of the vegetable ; the o<her
consecutive, entirely chemical, and capable of taking place beyond the influ-
ence of vitality, is the transformation of starch into dextrine and sugar, by the
action of diastase.

" When a liver removed from the living body continues for a certain time
still to produce sugar, it is evident that the vital phenomena of the formation or
secretion of the glycogenic matter has ceased, but the chemical phenomena
continue if the conditions of humidity and heat necessary for its accomplish-
ment are present. In the same manner, in the seed separated from the living
plant, the vital phenomena of the secretion of starch has ceased, but, under
the influence of the requisite physico-chemical conditions, the starch may be
transformed into dextrine and sugar, by the aid of diastase. In fine, it is
easy to see, by similar parallel observations, that the formation of sugar in the
liver of animals, passes through three successive series of transformations,
altogether analogous to those of the formation of starch, of dextrine, and of
sugar in the seeds of vegetables." — Moniteur de Hdpitaux, April 14, 1857.

2. Researches relative to the Influence of Alkali's and Alkaline Carbonates in
Destroying Glucose. — M. Jeannel communicated, some time since, to the Im-
perial Academy of Medicine, a memoir on this subject, which was referred to
a committee consisting of MM. Poggiale, Lecanu, and Caventou.

On the 12th of May, M. Poggiale presented a very interesting report in re-
gard to it, a summary of which we translate from the Moniteur des Hopitaux
(May 14, 1857).

The destruction of sugar in the system may be considered as a phenomenon
of combustion analogous to those which take place out of the system. Some
chemists think that the concurrence of alkaline carbonates is necessary for the
decomposition of sugar in the economy, and that in diabetes the passage of
glucose into the urine is due to a want of alkalinity of the blood; but direct
experiments do not confirm this ingenious theory, which is supported only by
analogy. The researches of MM. Lehmann, Bouchardat, and Bernard have
proved, on the contrary, that the blood of diabetic persons preserves its alka-
line properties; other experiments of Lehmann, Bernard, and Poggiale have
proved that the alkalies of the blood do not promote the oxidation of sugar.

Direct experiment and some clinical facts have shown, on the other hand,
that certain derangements of innervation, of the circulation, and of haematosis
appear to render the oxidation incomplete, and to determine the passage into
the urine of a certain quantity of glucose.

M. Poggiale, in a memoir presented to the Academy towards the close of the
year 1855, examined the action of the alkalies, alkaline carbonates, and bicar-
bonates upon the glucose out of the system, and it has been demonstrated by
many experiments that in the laboratory, as in the system, the carbonate of
soda does not act upon glucose, and that it is necessary to raise the tempera-
ture of the mixture to 95° for action to take place.

M. Jeannel has employed in his experiments, solutions in distilled water 0.5
gr. per cent, of dried sugar candy, and converted it into glucose by means of
tartaric acid.

These solutions of glucose added to various reactive agents have been put to
digest for different periods, sometimes in a bottle imperfectly stopped and con-
stantly briskly shaken, at others in a bottle entirely filled and closely stopped.
No. LXVIL— July 1857. 14

206

Progress of the Medical Sciences.

[July

In the first series of experiments, the author found that in equal weights caus-
tic soda acted more upon glucose than caustic potash did. The result was the
reverse when these alkalies were employed in the proportion of their chemical
equivalents. Air is not required for the destruction of glucose by the alkalies
in excess, but it evidently favors it. The decomposition of glucose by the
alkalies is in proportion to the time and the temperature.

Carbonate of potash attacks glucose at the temperature of about 55° in con-
tact with the air, and when it is in great excess it decomposes it even without
the presence of air. The difference of the action of the two alkaline carbonates
upon glucose is such that it may serve to distinguish them.

The bicarbonates of potash and soda do not act upon glucose at a lower
temperature than 90°, and what is singular the bicarbonate of soda has the
most marked destructive action.

M. Jeannel nevertheless admits that in consequence of the unknown pheno-
mena which take place in the organism, the bicarbonates diminish the propor-
tion of sugar in the urine of diabetic persons, and consequently exercise some
influence over the organic destruction of glucose.

3. On a tut little known Function of the Pancreas, the Digestion of Azotized
Food. — M. L. Corvisart communicated to the Imperial Academy of Sciences
(April 6th, 1857) an interesting memoir on this subject.

Purkinge and Pappenheim asserted (in 1839) that they had obtained from
the pancreas a liquid, endowed, like the gastric juice, with the property of dis-
solving azotized food, but hitherto it has not been proved to possess the power
of effecting digestion. The pancreatic juice, in digesting albuminoid aliments,
effects in them a transformation identical, or analogous to, that which the sto-
mach produces. But the pancreatic juice acts only on the food which has
escaped gastric digestion. The portion of the food transformed by the gastric
juice is a definite product upon which the pancreas does not act.

Pancreation acts by itself, independent of the surrounding medium ; so that
in intestinal digestion, the pancreatic juice, whether neuter, acid, or alkaline,
dissolves the same quantity of food, and produces a similar albuminose.

When the two digestive fluids are separated, they exercise their function in
full, and thus double the product of digestion. If they come together in their
pure state, the two digestions are not performed ; instead of double the quantity
being digested, digestion does not take place. The two ferments (pepsine, pan-
creatine) destroy each other. In the normal state, nature prevents this conflict
by three means : 1st, by means of the pylorus which separates the two ferments;
2d, by the gastric digestion itself, during which the pepsine is destroyed ; and
3d, by the bile which destroys in its course the activity of the pancreatine. This
conflict has, without doubt, been the cause of my failure, when I have admi-
nistered pancreatine for the relief of derangements of the second digestion, as
I have given pepsin for those of the first. During the digestive period, there is
formed as much pepsine as pancreatine ; if the gastric juice appears more
abundant, it is because it is more watery ; if the pancreatic juice appears
thicker, it is because it is less diluted. The bile does not precipitate the pro-
duct resulting from digestion performed by the stomach, so that digestion
is destroyed, or requires to be done over again ; on the contrary, the acid of
the latter precipitates the bile itself. In fact, the precipitate is neither formed
nor destroyed in an alkaline medium ; it is the same as regards the bile. —
Moniteur des Hopitaux, April 21, 1857.

4. Digestion and Absorption of Fatty Substances without the Concurrence of
the Pancreatic Juice. — In July, 1856, M. Colin, of Alfort, read to the Academy
of Medicine a memoir on this subject. At a meeting of the Academy on the
21st of April last, M. Perard made an interesting report on this memoir.

We have room only for the following conclusion which he presents : —
" Since in animals, of the bovine species, three or even four days after the
excretory duct of the pancreas has been tied, and the pancreatic juice is made
to flow out of the economy, there may be obtained from the thoracic duct, in
24 hours, more than 40 litres of perfectly emulsioned chyle, from which may

1857.]

Anatomy and Physiology.

207

be extracted by ether a notable quantity of fat, the pancreatic juice in these
animals is not necessary either for the absorption of fatty bodies or for the
formation of emulsioned chyle."

M. B. says necessary, and not useful, and his conclusions refer only to ani-
mals of the bovine species, though analogy would support him, he states,
in further generalizing. — Moniteur des Hopitaux, April 25, 1857.

5. Alcoholic Fermentation. — M. Bertdelot, in a memoir, read to the Im-
perial Academy of Sciences (April 6, 1857), states that he has produced
alcoholic fermentation in several substances which he had been led to consider
as approximating sugars, especially glycerine, mannite, and dulcine. After
giving circumstantial details of the circumstances under which this fermenta-
tion is produced, he concludes his memoir with the following summary : —

From all the facts which I have stated, glycerine, mannite, dulcine, sor-
bine, sugar of milk, cane sugar, and glucose belong to the same general class
of organic compounds characterized not only by analogous organic composi-
tion, physical qualities, and chemical functions, but also by the singular pro-
perty of being decomposed by the influence of lactic, acetic, and butyric acids.
This disposition to ferment, which is very marked in glucose, is less so in
cane sugar, still less in sugar of milk and in sorbine, and is called into action
with greater difficulty in substances containing an excess of hydrogen, as man-
nite, dulcine, and especially glycerine.

These substances, which are less readily changed by the action of heat and
of reagents, offer also greater resistance to the influence of azotized ferments ;
nevertheless the similar metamorphoses which they may undergo under this
influence tend to ally them with the sugars properly so called.

If we take into consideration that these analogous bodies are abundantly
found, free or combined, in vegetable tissues — that they attach themselves
directly to the insoluble principles which constitute the network of these tis-
sues— finally that most of the phenomena of vegetable physiology seem to
result from their transformations, it will be easy to understand how interesting
is the study of their reactions. The metamorphoses which they undergo by
means of fermentation offer an especial interest, on account of the resemblance
between these phenomena, which are so different from common affinity, and
vital phenomena, properly so called. To study fermentations, to guide them
at will, so as to produce definite chemical transformations, is to put in play
mechanisms analogous to those which preside over the metamorphoses of mat-
ter in living beings. — Moniteur des Hopitaux, April 21, 1857.

6. On the Mode of Action of the Gastric Juice. Dr. Blondlot, of JNTancy, in
various papers on digestion formerly published, endeavoured to prove that
the gastric juice only produces a softening of the protein or albuminoid matters
which facilitates their division by the slightest mechanical means. In a recent
paper [Moniteur des Hopitaux, 9 May, 1857) he states a remarkable fact, which
may throw some light upon the chemical modification under the influence of
which these matters thus lose, in part, their cohesion.

It is known that the gastric juice is but slightly acid, and that without the
species of ferment to which this fluid owes its specific powers, its acid principle,
whatever may be its nature, would remain perfectly inert in presence of the
azotized matters which constitute a part of the food.

With a view of examining the action of more concentrated acids upon these
matters, Mr. B. introduced various of these substances, such as cooked and
raw meat, many organic tissues, albumen coagulated by heat, &c, into tubes
closed at the end, with water acidified with a tenth part of common sulphuric
acid, shaking them from time to time, and observed with surprise that under
an influence of a temperature of forty degrees, at the end of twenty-four hours,
these substances, which had not changed in appearance, and had neither ab-
sorbed nor exhaled any gas, had become so softened as to be converted, when
stirred with a glass rod, into a species of bouillon apparently homogeneous and
perfectly similar to that produced from them by means of the gastric juice. He
repeated this experiment a number of times, changing the organic matter sub-

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Progress of the Medical Sciences.

[July

mittcd to experiment, and always obtained precisely similar results ; different
gelatinous substances, especially the gelatin offish, placed in similar conditions,
lost their property of becoming a jelly by cold, precisely as they do under the
action of the digestive fluid.

Further experiments have shown that the sulphuric is not the only acid that
produces the above mentioned effects as well upon protein matter as upon gelatin.
Other inorganic acids produce them also, but with less force. With regard to
the organic acids, none soften the albuminoid matters, at least at the tem-
perature of forty degrees and above [below ?] ; if heated more, they produce a
similar softening. Besides, whatever may be the acid used, the matter pre-
serves all its exterior appearances, and covered by the liquid that has acted
upon it, may remain for a long time free from change.

These facts appear to Dr. B. to possess value from the conclusions that we
can draw from them. They demonstrate the exactitude of an analogy, some
time since indicated by Mr. Dumas, between the gastric ferment (gasterase of
some authors) and diastase, properly so called, in this respect, that the par-
ticular action exerted by any of these ferments may also be artificially pro-
duced by identical chemical agents, namely, diluted acids.

But as the amylaceous molecule only appropriates to itself the elements of
water when either acids or diastase are made to act upon it, it is a legitimate
induction that the protein molecule which is submitted to the same influences,
is itself only hydrated ; only the result of this hydratation is not identical, since
the union of water with starch produces a true metamorphosis, resulting in its
conversion into sugar, whilst -the introduction of water into the protein mole-
cule produces simply a diminution of cohesion.

In support of this theory, which makes the water of hydratation perform so
important a part in digestion, Mr. B. states that if we previously dry in a tem-
perature of 100 degrees, the matters submitted artificially to the action of
either pure gastric juice or diluted acids, at the temperature of 40 degrees,
they prove completely refractory, and do not become any more softened than
when placed in simple water, as if a certain degree of natural hydratation,
was indispensable to enable the albuminoid matter to combine with the excess
of water, which produces its softening, just as happens to certain inorganic pro-
ducts, which, once completely deprived of water, cannot resume it without
great difficulty.

On the whole, Mr. B. is persuaded, that the organic principle which charac-
terizes the gastric juice is only a peculiar species of diastase (which he pro-
poses hereafter to name hydrastase, to distinguish it from the preceding), and
the modification it produces in azotized matters consists in a simple hydratation.
This will explain how, whilst preserving their appearance, and without essen-
tially changing their nature, these matters so easily undergo the dissegregation
which converts them into chyme.

7. Quantity of Air inspired at every 5, 15, and 30 minutes of the Day and
Night, and under the Influence of Exercise, Food, and Medicines — on the Tem-
perature of the Body, &c. — Dr. Edward Smith, Assistant Surgeon to the Hospital
for Consumption, Brompton, communicated to the Royal Society (April 30,
1857) some very interesting experiments on this subject.

This paper was in continuation of a series of inquiries began in 1855, in
reference to respiration and pulsation in health and disease, and having for
their object to determine the serial changes in the twenty-four hours. Those
on the rate of the functions made at every hour of six days and nights, in
phthisis, and of three days and nights, in health, have already been published
in the Transactions of the Royal Medico-Chirurgical Society. This paper is
devoted chiefly to the determination of the quantity of air inspired under
similar circumstances, but the rate of respiration and pulsation, the depth of
inspiration, the temperature, and the barometric pressure, are also recorded.
The inquiries were made upon and by the author, and by the aid of a spiro-
meter, consisting of Glover's patent dry gas-meter, of improved manufacture,
of reversed action, so as to measure inspiration, and graduated to record from

1857.]

Anatomy and Physiology.

209

1 to 1,000,000 cubic inches. When in use, an ori-nasal mouthpiece was em-
ployed, connected with the spirometer by vulcanized caoutchouc tubing. The
first part of the paper was devoted to a consideration of the total quantity of
air breathed in the 24 hours. This was effected by three experiments. 1. By
wearing the instrument during 5 minutes at the commencement of every J of
an hour, from 5 A. M. to P. M, ; and every J hour, from 6J P. M. to 3^ A. M.
Exercise and food were taken intermediately, but sleep was necessarily excluded.
The inquiry was always made in the sitting posture. 2. By wearing it con-
tinuously during the whole twenty-four hours, except at intervals amounting
collectively to 40 minutes, and recording the results every five minutes. Food,
exercise, and sleep were taken, and the periods recorded. The mind was occu-
pied in reading or in games, and the whole day passed in a normal condition.
Xo fatigue was felt after the inquiry. 3. By an inquiry similar to the last,
but continued only from 6f P. M. to 5| A. M., and having for its object to de-
termine the precise influence of sleep. In the first inquiry the average returns
were, after supper, 354 cubic inches; before breakfast, 358 cubic in.; after
breakfast, 445 cubic in.; after dinner, 448 cubic in.; and after tea, 454 cubic
in. per minute. In the second inquiry, the minimum quantity was 21,230 cubic
in., and the maximum nearly 40,000 cubic in. per hour. The average of the
lying posture was 450 cubic in. per minute ; and of the sitting posture, 533
cubic in. per minute. The third showed a minimum respiration of 352 cubic
in. per minute during sleep. From these facts was deduced the wear of sys-
tem in various classes of the community, and it was shown that different classes
must breathe daily quantities of air, varying from 700,000 cubic in. to 1,400,000
cubic in.

The second part of the paper contained the results of inquiries into the in-
fluences of the following agents: —

1. Those which increase respiration — viz., posture of body walking and run-
ning at various amounts of speed, walking in the sea, riding on horseback in
the various spaces, riding in carriages and on the railway in different classes,
and on the engine at various rates of speed, the labour of the tread-wheel,
ascending and descending steps, rowing, swimming, Marshall Hall's ready
method, reading and singing, carrying various weights at a certain speed, cold
bathing; albumen (egg), gelatin, beefsteak, oatmeal, wheaten-bread, potatoes,
milk, suet and milk, sugar, rum, tea, coffee, ether, sunlight, heat.

2. Those which decreased the quantity of air breathed — viz: darkness, cold
air inspired; all fats, as cod-liver oil, "olive oil, butter, beef fat; arrowroot,
brandy, wine, kirchenwasser, compound and fetid spirits of ammonia, opium,
morphia, hydrocyanic acid, tartar emetic; and salines, as chloride of sodium,
and febrifuge medicines.

3. Those which had a mixed effect — viz : chloroform, chloric ether, and amy-
lene. Digitalis first increased and then decreased the quantity.

In each instance the instrument was worn during 5 minutes at one time, and
the results averaged per minute. In reference to exercise, that agent was con-
tinued from 3 to 10 minutes before the influence of it was sought. When ascer-
taining the effects of food and medicines, the sitting posture was exclusively
selected, and was maintained for some time before the inquiry commenced,
and whilst the preliminary observation was made which constituted the basis
quantity. An inquiry was made directly after having swallowed the substance
under investigation, and repeated during the first quarter of an hour, and sub-
sequently at the beginning of each succeeding quarter of an hour for about two
hours. The periods selected for the inquiry were before breakfast and at least
three hours after a meal, so as to avoid the perturbing influence of previous
food. The author strongly insisted upon the following circumstances being
noted and maintained unchanged during such inquiries — viz : posture, sun-
light, temperature, season of the year, exertion, and mental emotions. He
recorded the number, absolutely and also relatively to the basis quantity re-
corded immediately before the investigation ; but in reference to the influence
of food and medicines he believed the latter only to have importance. He found
that the various kinds of exercise increased the quantity of air inspired per
minute up to seven times the quantity breathed normally in the quiet lying

210

Progress of the Medical Sciences.

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posture. In reference to food, the most interesting facts were, that whilst all
fats and pure starch decrease respiration, sugar largely increases it; and that
albumen, gelatin, milk, and all ordinary nitrogenous diet, increase it to a
moderate degree only. Also, that whilst brandy, wine, and kirchenwasser
greatly decrease respiration, rum largely increases it. Ammonia gave oppo-
site results, according to the preparation and dose, which accounted for the
difference of opinion as to its influence. The author was assured of the cor-
rectness of Dr. Billing's assertion, that ammonia may be a sedative, and,
moreover, that it is a most powerful one. Certain agents, as digitalis, had a
contrary action during their influence, first to increase, and then to decrease
respiration. The most powerful respiratory excitants were — ether, tea, and
sugar; and the most powerful depressants were, some preparations of ammonia,
opium, morphia, tartarized antimony, kirchenwasser, and sleep ; and these,
with salines, which have the same action, are the common antiphlogistic and
febrifuge remedies. Sunlight increased, darkness decreased respiration ; heat
increased, and cold decreased respiration, when the difference was considerable ;
cold applied to the skin increased, but cold air inspired decreased respiration.

In the third part were contained the results of inquiries into the temperature
of the expired air, showing that it was from 4° to 8° lower when inspiration
had been effected through the mouth than through the nose — a fact teaching
the importance and the benefit of breathing through the nostrils only in cold
weather. It was also proved that a part of the body may have its temperature
increased by friction, &c, 20° in a few minutes, without having received any
increase of heat externally — a fact implying that under such circumstances the
heat of the surface is rather due to a larger distribution of blood there than to*
any increased generation of heat.

The tables and diagrams accompanying the paper contained the record of
1200 series of observations, and various deductions of professional and general
interest were appended. The subject was entirely novel, as previous observers-
had limited their attention to the chemical changes in respiration, and at irre-
gular intervals only.

Professor Sharpet bore testimony to the careful precautions and patient
labour with which the author's experiments had been made, as peculiarly cal-
culated to lead to trustworthy results. It was a curious circumstance that
brandy and rum should act differently on the respiration — the former decreas-
ing, the latter increasing it. He (Dr. Sharpey) agreed with the opinion ex-
pressed by Dr. Thompson, that with increase of respiration, an increase of
carbonic acid must be expected, although not necessarily proportional. The
inquiry instituted opened questions of remarkable interest. The different
amount of respiration in men and women was curious. Andral andGavarret,
for example, had observed that the amount of respiration in women, particu-
larly after puberty, was much less than that of men. Dr. Smith's remarks on
the influence of light confirmed those of other investigators. Frogs had been
observed to have their respiration increased by this agent. He (Dr. Sharpey)
believed not only through its influence on the skin, but probably also through
the medium of the eye. He considered that the harmony between the author's
results and those obtained by the best previous observers was evidence of their
truthfulness.

Professor Carpenter gave an interesting description of the apparatus em-
ployed by the author, and showed the great advantage derivable from a
lengthened and continuous series of observations, so contrived as to avoid the
restraint and discomfort which some other modes of experiment involved,
whilst free from different sources of uncertainty present in observations made
in confined chambers without the use of any apparatus. Carrying out such
observations continuously for twenty-four hours without fatigue implied normal
conditions. Dr. Carpenter referred to the remarks made on light and darkness
in relation to respiration. He knew of instances in which persons were affected
with laborious and distressing breathing if the candle was extinguished during
their sleep. Such instances were extreme, but they were favourable to the
opinion that light under ordinary conditions had some effect as a stimulus to
the reflex actions concerned in respiration.

1857.]

Anatomy and Physiology.

211

8. Complete Obliteration of the Thoracic Aorta. — Mr. Sidney Jones describes
{Med, Times and Gaz., May 16, 1857) the following unique specimen. The
subject from which it was obtained was brought into the dissecting-room of
St. Thomas' Hospital, from a workhouse. He was a male, and aged forty-five
years, but no particulars as to his state of health could be obtained beyond the
account that some little time ago he had been under care in Gay's Hospital on
account of chest disease. His lungs showed evidences of past inflammation.
It was evident that the condition of the aorta had existed for a long time, and
most probably the collateral circulation had become sufficiently established to
prevent any material inconvenience from being felt. There was no reason to
think that this lesion had anything to do with the fatal illness. The specimen,
carefully dissected and in a dried state, now forms part of the St. Thomas'
Museum. The obliteration is situated at the commencement of the descending
thoracic aorta, just below the junction of the ductus arteriosus with the termi-
nation of the arch. In the dried state it looks as if merely a constriction of
the vessel existed; but in the recent state the obliteration was seen to be com-
plete, a ligamentous cord about half an inch in length uniting the two ends of
the artery.

Just above the obliteration is a quantity of atheromatous deposit, involving
at that point nearly the whole circumference of the vessel. The arch is much
enlarged, as are also its three arterial trunks. The latter were at least double
their usual calibre.

Below the obliteration the aorta forms a bulbous dilatation, which extends
about the length of two vertebrae, viz., from the upper border of the fifth to the
lower border of the sixth dorsal vertebra. Its diameter is very much increased,
and varies from an irich and a half to two inches. Opening into this dilatation
are four intercostal arteries on each side ; those of the right side are somewhat
the largest, the upper one being about the size of a very large goose-quill.
They are very tortuous, and gradually diminish in size from above downwards,
the sixth intercostal on each side having about its normal diameter.

The aorta below the dilatation is also enlarged, but begins to assume its
normal calibre opposite the upper border of the ninth dorsal vertebra, having
gradually diminished in size, and being thus rendered somewhat infundibu-
liform.

The frst aortic intercostal of the right side is very tortuous, passing outwards
between the third and fourth dorsal vertebrae, to the head of the fourth rib ;
then ascending vertically to the head of the third rib ; having first given off
from its inner side a branch, about the size of an ordinary radial, which runs
upwards along the centre of the bodies of the three upper dorsal vertebrae, and
anastomoses with a branch from the inferior thyroid of the subclavian. The
artery (i. e. first intercostal) turns outwards above the third rib, gives upwards
a large branch, which anastomoses with the superior intercostal of the subcla-
vian, and then divides into two branches; one continues its course between the
second and third ribs, the other is double its size, and passes through to the
back.

The second and fourth right aortic intercostals are large, and divided like-
wise into an anterior and posterior branch ; the posterior branch in each case
is much larger than the anterior.

The third intercostal of this side is much smaller than the first, second, and
fourth, and gives off a very small posterior branch, the greater part of the
artery continuing its original course.

The frst aortic intercostal of the left side has its calibre somewhat less than
that of the opposite side ; it is very tortuous, and ascends to the interval be-
tween the second and third ribs; it gives off one branch (size of small radial),
which runs behind the oesophagus, and anastomoses with a branch of the infe-
rior thyroid. It then divides into an anterior and posterior branch, the last of
which forms the greater bulk of the artery, the anterior not being much larger
than an ordinary intercostal.

The posterior branch of the second aortic intercostal of this side is much
larger than the anterior ; the other intercostal arteries of this side have their
posterior branches much smaller than the anterior.

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Progress of the Medical Sciences.

[July

Branches of Right Subclavian. — The internal mammary and transversalis
colli arteries are very large, and have a diameter little less than an ordinary
subclavian. The transversalis humeri is also large, and takes its origin from
the third part of the subclavian.

1. Transversalis colli. — The posterior scapular branch takes its ordinary
course along the vertebral costa of the scapula ; its principal branches are
directed inwards, three or four large trunks running inwards, and anastomosing
directly with the large posterior branches given off from the intercostal arteries.

2. Internal mammary. — The branches given off from the outer side of this
artery, and which run along the three or four upper intercostal spaces, are
large, and anastomose directly with the anterior branches of the intercostal
arteries. The musculo-phrenic forms free anastomoses with the diaphragmatic
arteries of the abdominal aorta.

3. Inferior thyroid is larger than usual; its glandular branches are about
their normal calibre; a branch runs downwards and forwards to the oesopha-
gus, and meets an ascending branch, given off from the first aortic intercostal.

4. The vertebral is of little more than ordinary diameter.

5. The superior intercostal is about the size of the internal mammary and
transversalis colli arteries ; it gives off a large deep cervical branch, and then
continues its course tortuously to the first intercostal space, at which point a
large posterior branch is given off.

Branches of Left Subclavian. — The vessels of this side are given off just as
on the right side, but their calibre is smaller. The subclavian on each side is
reduced to at most half the diameter it had before the giving off of its trunks.
The deep epigastric on each side is very large, having about the diameter of
the corresponding internal mammary ; very free anastomoses are formed be-
tween it and the last-named artery.

We find, therefore, that the principal communications by which the circula-
tion was carried on are —

1. The internal mammary, anastomosing with the intercostal arteries by
means of the musculo-phrenic and comes nervi phrenici, with the diaphrag-
matic of the abdominal aorta, and largely with the deep epigastric.

2. Superior intercostal, anastomosing anteriorly by means of a large branch
with the first aortic intercostal, posteriorly with the posterior branch of the
first aortic intercostal.

3. Inferior thyroid. — A branch, about the size of an ordinary radius, forms
a communication between the first aortic intercostal and this vessel.

4. Transversalis colli. — Very large communications with the posterior
branches of the intercostals. The size of this artery, with its large anasto-
mosing branches, first led one to look for some obstruction.

6. The branches going to the side of the chest were large, and anastomosed
freely with the lateral branches of the intercostals.

MATERIA MEDICA AND PHARMACY.

9. Experim ents on the Action of Pepsin. By Edward H. Sieveking, Lect. on
Mat. Med. — Those who have employed pepsin in the treatment of dyspepsia will
probably be disposed to admit that it possesses a considerable therapeutic value.
Into this question I do not now propose to enter ; but as it is likely that the more
extended use of the article, provided that we can secure its being properly pre-
pared, will establish its claim to a permanent place in our materia medica, it
may not be uninteresting to relate a few experiments that I have recently made
with pepsin. The experiments were made with specimens of Boudault's pep-
sin,1 of Trommsdorff's pepsin, and of Oberdorffer's2 dried pig's stomach. Bou-
dault's pepsin (poudre nutrimentive) is acid to the taste, and to litmus, owing

1 Obtained from Messrs. Squires', the Queen's Chemists.

2 These two specimens were kindly supplied to me by Messrs. Hilgenberg and
Schacht, of Houndsditch.

1857.]

Materia Medica and Pharmacy.

213

to the lactic acid it contains; it is a stone-gray powder, consisting mainly of
starch and dibris of epithelium, as shown respectively by the iodine test and
the microscope. Trommsdorff's pepsin is also a stone-coloured powder, caking
and gritty to the touch, strongly acid to the taste and to litmus paper, and very
hygroscopic ; under the microscope, the whole appeared composed of starch-
granules of various sizes, which gave a blue reaction with iodine. On addition
of water, the granules swelled, became ovoid, and showed faint concentric lines,
witli here and there a radiating fissure,
ft The dried scrapings of the pig's stomach also presented a stone colour, but
of rather a more reddish hue ; the substance was pulverulent and soft, acid to
test paper, and consisting of epithelium and debris of animal tissue ; not ma-
terially altered by the addition of acetic acid, and containing a few ovoid par-
ticles, which were blued by iodine.

Of each of these I weighed out two specimens of 4 grains each, and submitted
cubic pieces of hard-boiled white of egg, of 20 grains each, in half an ounce of
distilled water, to their action. To one specimen of each, one drop of strong
hydrochloric acid was added, and the whole series was exposed to a temperature
of 100° Fahr. The glasses were left for above twenty-four hours, and the fol-
lowing is a summary of the effects produced: —
The albumen treated with —

Loss.

1. Boudault's pepsin, weighed over 16 grs. . . nearly 4 grs.

2. " " with hydrochloric acid, weighed

under 10 grs. . . . above 10 "

3. Trommsdorff's pepsin, weighed over 18 grs. . . "20 "

4. " " with hydrochloric acid,

weighed over 12 grs. . " 8 "

5. Pig's stomach, weighed over 20 grs.

6. " " " 15 grs 5 "

In the case of 2 and 4 the action was very marked, the edges of the albumen
were rendered extensively clear and transparent. Nos. 1 and 3 looked as if
they had scarcely been affected ; No. 6 was slightly digested, but much less
than Nos. 2 and 4. The albumen in Nos. 3 and 5 looked as if it had undergone
no change, and it was manifest that No. 5 had even absorbed water, and had
thus increased in weight. The liquid was in each case tested for albumen ;
feeble indications of its presence were afforded by the water of Nos. 2, 3, 4, 5,
and 6.

About a fortnight after the last series of experiments I repeated them, with
nearly the same results. The same quantities of white of egg and pepsin were
used, two drops of hydrochloric acid were added to one specimen of each kind,
and the whole was exposed for some hours to a temperature of 110° F., and the
glasses shaken from time to time. At the termination of the experiment, the
albumen in —

1. Boudault's pepsin, weighed 15 grs 5 grs. loss.

2. " with acid, weighed 12 grs. . 8 " "

3. Trommsdorff's pepsin, weighed 17J grs, . . 2J " "

4. " with acid, weighed 17 grs. . 3 " "

5. Pig's stomach, weighed 21 grs. . . . 1 gr. gained.

6. " " with acid, weighed 8 grs. . . .12 grs. loss.

It is stated in my notes that the liquid of Nos. 1, 2, and 4 gave feeble indi-
cations of the presence of albumen. The albumen in Nos. 2 and 6 had become
translucent to a great extent, while the albumen in the other glasses remained
opaque. The discrepancy between the two serials is, that in the second the
action of the pig's stomach with the acid was so much greater than Tromms-
dorff's pepsin, or even than Boudault's. The two sets of experiments agree in
demonstrating that in all instances the solvent power of the preparation was
much promoted by the addition of the hydrochloric acid ; and that imperfect
pepsin (as in No. 5 in each set) not only does not promote, but actually retards,
digestion. We must not, therefore, allow our dyspeptic patients, on the mere

214

Progress of the Medical Sciences.

[July

strength of the pepsin we prescribe, to take a larger quantity of food in the
first instance than we should otherwise order, but make certain of the peptic
power of the agent in the first instance, or Ave may aggravate instead of reliev-
ing his complaint. It is evident, also, that Boudault's is a powerful and trust-
worthy agent.

In submitting the above memoranda, I would only add that the conclusions
I have arrived at in relation to the therapeutic value of pepsin corroborate those
put forward by Drs. Corvisart and Ballard, and that I regard pepsin as an agent
which we may in many diseases of malnutrition prescribe with great benefit to*
our patients. — Med. Times and Gaz., April 4, 1857.

10. Chemical and Physiological Properties of Pepsin. M. Boudault read an
interesting memoir on this subject before the Socie'U de Pharmacie of Paris,
of which the following is an abstract. Pepsin is a compound found in the
gastric juice of animals, from which it is obtained as a syrupy substance, by
simple evaporation. It is also precipitated in a neutral state by alcohol. Me-
tallic salts throw it down without altering its physiological properties, which
reappear when the pepsin is separated from the salts which have precipitated
it. Gastric juice contains 1.25 of pepsin, and 1.75 of saline matters; the rest
consists of water and lactic acid, which latter plays an important part in the
phenomena of digestion. From his experiments M. Boudault concluded that
pepsin is secreted in the neutral state, but that it is to its action as a ferment
that the gastric juice owes its property of converting glucose into lactic acid.
On the other hand, he proved that pepsin alone, that is, in the neutral state,
cannot effect digestion; it is only when glucose is changed into lactic acid that
digestion can take place. Hence the sequence will be, the salivary diastase
transforms the amylaceous principles of the food into glucose, which is con-
veyed into the stomach ; there this glucose meets all the elements necessary to
its change into lactic acid, and especially pepsin, the principal agent in this
modification, whence results the formation of gastric juice, and consequently
digestion.

Lactic acid is not, however, the only acid capable of effecting digestion.
Pepsin, acidulated with hydrochloric and acetic acids, also determines the for-
mation of gastric juice ; but digestion is never so complete as with pepsin,
acidulated with lactic acid.

M. Boud?ailt detailed some experiments demonstrating the equal efficacy of
artificial gastric juice prepared by himself, from pepsin obtained from the ren-
net of the sheep, with that of the natural fluid obtained from dogs.

The employment of pepsin as a medicine was naturally suggested by its
energetic action as a digestive substance. Dr. Corvisart, who was the first to
use it, obtained satisfactory results, and it was the pepsin of herbivora which
he employed (Bulletin de Therapeutique, vol. 47, p. 320). M, Boudault adminis-
ters pepsin mixed with starch, tlried at a temperature of 212° F. In this form
it can be mixed with a number of medicinal substances, which do not interfere
with its therapeutic action. For example, with hydrochlorate of morphia, in
cases of violent cardialgia; with strychnia, where it is desirable to stimulate
the peristaltic motions of the stomach ; with subnitrate of bismuth, lactate of
iron, carbonate of iron, iodide of iron, reduced iron, &c.

Pepsin is very efficacious in dyspepsia, and in the derangements of digestion
which usually attend recovery from serious or chronic diseases. Finally, it is
a powerful digestive agent in cases of consumption from insufficient nourish-
ment.

It is given in the first spoonful of soup, or before meals, rolled up in awafer,
and either in the acid or neutral state. In the former condition it replaces the
gastric juice, when the latter is not secreted in sufficient quantity in certain
morbid affections; in the neutral, that is, the slightly acidulated state, it is used
in cases where the stomach contains too great a quantity of acid. It is a
powerful remedy. — Bulletin General de Therapeutique, 30th January, 1857.

Dr. W. Stephens Squire gives the following as M. Boudault's process for the
preparation of pepsin. The rennet bags of sheep are opened and reversed,
and washed under a thin stream of water, to free them from alimentary mat-

1857.]

Materia Med tea and Pharmacy.

215

ters, &c. The mucous membrane is then carefully scraped off with a knife,
the cells are bruised in a mortar, and digested for twelve hours in distilled
water. The liquid is then filtered, and neutral acetate of lead is added, which
precipitates peptate of lead. This precipitate is collected and decomposed by
means of sulphuretted hydrogen. Pepsin is thus liberated in solution, and is
separated from the insoluble sulphide of lead by filtration. The filtered liquid
represents neutral gastric juice. It is, however, necessary that it should be
acid, and for this purpose lactic acid is added until the liquid exhibits the
same degree of acidity as a specimen of gastric juice obtained from the stomach
of a dog by means of a fistulous opening. If the artificial gastric juice thus
obtained be evaporated to dryness, at a temperature not exceeding 100° F., a
gummy mass is obtained, which attracts moisture from the air, and is alto-
gether a very unfit article either for sale or administration. In order to reduce
it to powder, M. Boudault simply evaporates his artificial gastric juice to a
syrupy consistence, and to this he adds dried starch in such proportion that
one gramme shall be capable of digesting four grammes of dry fibrin, when
the two are submitted together in the presence of water to the temperature of
the human body.

The substance thus produced is a fawn-coloured powder, cohering somewhat
together, and possessing a peculiar taste and odour. It yields to water the
lactic acid and the pepsin, producing a solution of a yellowish tint, with the
colour, odour, and taste of gastric juice. — Pharmaceutical Journal, March,
1857. '

11. Therapeutic Employment of the Pyrophosphate of Iron. — M. E. Robtquet
read (Feb. 10th, 1857) an interesting memoir on this subject before the Impe-
rial Academy of Medicine of France.

" Since," he remarked, " Mr. Graham made known the singular transforma-
tions produced by heat in phosphoric acid, chemists have carefully studied the
saline combinations into which the acid, molecularly modified, is capable of
entering. The most interesting of these salts are those formed by simple ig-
neous fusion, and, therefore, called pyrophosphates, and for this reason that
the pyrophosphoric acid corresponds to two equivalents of base. Industry has
already derived great advantage from the property possessed by pyrophosphoric
acid of combining with soda, and with gold or silver. In medicine, the pyro-
phosphate of iron has often been tried, and this might be expected, for oxide
of iron undoubtedly reacts on the functions of the blood, and the elements of
pyrophosphoric acid are found in the bones ; but it has soon been given up on
account of its liability to change, and of the great quantity of pyrophosphate
of soda necessary to retain it in solution in water. It struck me that these
inconveniences might be easily avoided without depriving the ferruginous salt
of any of its essential properties.

In medicine the essential characters of a good preparation of iron are, that
it shall readily dissolve in the fluids of the stomach without impairing their
digestive functions, that it shall be completely assimilated in the system, and
that it shall not act as an astringent. The pyrophosphate of iron possesses all
these properties ; its resistance to solvents is the sole difficulty which remains
to be overcome to entitle it to the first rank among the preparations of iron.

In studying the molecular constitution of this remarkable salt, it is easy to
see that it belongs to the class of bodies endowed with the character of poly-
morphism. Like sulphur, phosphorus, arsenious acid, and many other poly-
morphous substances, pyrophosphate of iron will therefore present great
differences in its chemical properties, according to the process adopted in its
preparation, and the temperature at which it has been obtained. By precipi-
tating a solution of persulphate of iron with one of pyrophosphate of soda,
taking care to operate at a temperature below 59° F., we obtain a gelatinous
precipitate, which is nothing else than pyrophosphate of iron (Fe2 03 3Ph 05),
dissolving with the greatest facility in a solution of pyrophosphate of soda.
If the ferruginous salt were obtained at a temperature above that just men-
tioned, and, a fortiori, at a boiling heat, a considerable quantity of pyrophos-
phate of soda would be required, and still we should obtain only an unstable

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solution, acquiring a black colour, and having an insupportable taste. In fact,
whatever precaution we take, not less than four parts of pyrophosphate of soda
are required to dissolve sixteen of the gelatinous ferruginous precipitate, re-
presenting three parts of the salt dried at 212°. When the solution is prepared
in the cold, it keeps for some time without change, and might be converted into
a syrup which would keep tolerably well in close vessels for one or two months.
However, such a mixture contains too large a proportion of pyrophosphate of
soda, which gives it a disagreeable saline taste, and does not prevent it, after a
longer or shorter interval, from blackening on exposure to the air, and acquir-
ing a more and more decided metallic taste. It was, therefore, necessary to
seek for another solvent. That which I have found to succeed best is the citrate
of ammonia, a salt which has the double advantage of being capable of em-
ployment in very small quantity, and of chemically concealing iron from
reagents.

The solution of pyrophosphate of iron in a citro-ammoniacal liquor keeps
for whole months without undergoing any change, and yields a syrup free from
the intolerable taste of ferruginous compounds. Potash, ammonia, and the
alkaline carbonates, do not give, with pyrophosphate of iron so dissolved, the
reaction peculiar to the salts of iron.

MM. Dumas, Laurent, and Gerhardt, in their valuable researches on the
theory of substitution, have shown that it is possible, in a number of organic
compounds, to substitute iodine, bromine, or chlorine, for hydrogen, without
disturbing the molecular equilibrium, or the chemical reactions of the funda-
mental compound. Thus, in chloruretted alcohol or chloral, nitrate of silver
produces no turbidity, because the chlorine of the chloral behaves, not as the
chlorine of hydrochloric acid, or of a metallic chloride, but as the hydrogen of
which it has taken the place. Now, destroy the chloral, either by combustion
by nitric acid, or by any other energetic oxidizer, and you will rediscover the
chlorine with all its characteristic reactions. In like manner, in the salt of
which I am treating, the iron is chemically concealed; its presence is no longer
manifested by the most sensitive reagents ; potash and ammonia no longer pre-
cipitate it as an oxide; and its properties are so masked that it is necessary
completely to break up its molecule in order to be able to estimate the iron, or
to discover its reactions.

If I enter a little at length into this subject, it is because I am persuaded
that therapeutics will one day derive the greatest advantage from medicines,
the active element of which is chemically concealed. Such compounds are, in
fact, very slowly disaggregated in the process of digestion, and the system,
absorbing them atom by atom, will conceal them integrally.

The process of solution being once found, nothing is easier than to trans-
form the pyrophosphate of iron into comfits, syrup, or lozenges; the latent state
in which it exists in this new salt enables us to mix it with wine of bark, and
to obtain from it a powerful tonic, without having to fear the blackish dis-
coloration and inky taste which are always produced when a salt of iron is
brought into contact with fluids more or less highly charged with tannin.

In whatever mode the citro-ammoniacal pyrophosphate of iron be adminis-
tered, it has absolutely no taste, and patients not only bear it readily, but feel
the best effects from its use. I have seen it particularly useful in well-marked
cases of ansemia, chlorosis, and chronic urethritis.

To recapitulate, the pyrophosphate of iron, chemically considered, is a poly-
morphous salt, in which the metallic atom is concealed from reagents ; it con-
tains, by weight, 21.11 per cent, of iron. In a therapeutic point of view, the
facility with which it is assimilated by the system, the absence of all styptic
taste, its perfect solubility in water, the influences, finally, which it exercises
on the composition of the bones and the functions of the blood, entitle it to the
first rank among ferruginous compounds.

Formulae. Syrup of I on. — Pyrophosphate of iron, two and a half drachms ;
simple syrup, twenty-nine ounces ; syrup of orange flowers, three ounces ; make
a syrup by simple solution, and colour with a sufficient quantity of tincture of
cochineal or alkanet. Each drachm of the syrup contains about six-tenths of
a grain, and a tablcspoonful about three grains, of the salt of iron.

1857.]

Medical Pathology and Therapeutics.

217

Ferruginous Comfits. — Pyrophosphate of iron, one ounce and five drachms;
divide into 500 comfits, each of which shall contain a grain and a half of the
salt.

Ferruginous Wine of Baric. — Pyrophosphate of iron, two and a half drachms ;
extract of pale bark, seventy-seven grains ; white wine, thirty-two ounces ; to
be made secundum artem." — Journ. des Connaissances Med. et Pharm., Feb. 20,
1857.

12. Therapeutic Properties of Iodide of Potassium. — MM. Demarquat and
Gustin communicated to the Imperial Academy of Medicine (April 7, 1857) a
note on this subject. They state that the favourable effects obtained from the
use of the chlorate of potash in different affections of the buccal mucous mem-
brane, have led them to inquire whether the therapeutic properties of this salt
were not common to other salts having a striking chemical analogy with it.
Profiting by this idea they have tried the past year, in the service of M. Monod,
the iodide of potash, and they state that their confidence in it augments daily.
They think it may replace the chlorate of the same base, the iodide acting
more promptly, more energetically, and in a less dose than the chlorate. Fur-
ther, they say that the iodide has been beneficial where the chloride had
failed. — Moniteur des Ropitaux, April 11, 1857.

13. Employment ef Amylene for Children. — M. Giraldes, as the result of the
employment of amylene in place of chloroform in the cases of twenty-five child-
ren of different ages, draws the following conclusions: 1. It is respired more
easily and with less struggling than chloroform. 2. Anoasthesia takes place
very rapidly. 3. The sleep is more calm and natural, and is unaccompanied
by stertor. 4. The patients rapidly return to their normal conditions. 5. It
does not induce nausea, vomiting, or cerebral congestion. 6. The patients suffer
no inconvenience afterwards, recovering all their cheerfulness. — Comptes Pen-
das, No. 10, 1857.

14. External Use of Clay. — Dr. Betz employs clay mixed with water, and
spread some lines in thickness upon rag, as a poultice in cutaneous, cellular,
and lymphatic inflammations, in panaritis, periostitis, periphlebitis, etc. The
application must be often renewed. He believes its utility is attributable to the
great affinity the clay has for water, so that, sprinkled upon suppurating sur-
faces, it quickly causes the absorption of the fluids, and the formation of a crust.
So, also, it absorbs water through the uninjured skin, which becomes wrinkled.
Its influence may be further attributed to its low temperature. — Med. Times and
Gaz., April 4, 1857, from Schmidt's Jahrb., Bd. 93.

MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL

MEDICINE.

15. On the Diseases of the Army of the East during the winter of 1854-5. —
By Dr. Tholozan. When the sickness began to show itself in large propor-
tions in the French army, M. Tholozan was among the civilians dispatched by
the Government to the seat of war. In the present paper he presents to the
Academie de Medecine a succinct account of some of the facts he observed at
Constantinople from December, 1854, to March, 1855. During this period, he
received about 1200 patients sent from the Crimea. In about a fourth of these,
the affections were slight and easily treated ; but 900 were the subjects of severe
disease, and of these 290 died.

The diseases which gave rise to this mortality were the same that filled all
the other hospitals of the Crimea and Constantinople, viz., cholera, dysentery,
scorbutus, and typhus. The cholera, here as in other armies, was due to an

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[July

accidental morbid influence arising from the choleraic medical constitution
which prevailed at the beginning of the war over a large portion of Western
Europe. It is not a disease proper to armies, though it often shows itself
among them when epidemic or endemic influences favour its development.
What had been already observed in India, Russia, Poland, and Algeria, ex-
hibited itself with identical pathological and epidemiological characteristics in
the Crimea. It is quite otherwise with regard to scorbutus, typhus, and dysen-
tery, which arise in armies, crowded garrisons, and besieged towns, displacing,
under these circumstances, other forms of disease which are observed in or-
dinary military life, during a period of peace. Thus, acute phthisis, which, in
England, France, and Germany, is a common disease in the army, and stands
in the foremost rank among the causes of death, is met with during a cam-
paign only in very small proportions. Typhoid fever, so frequent in hospitals,
is seldom met with under the hygienic conditions of actual warfare. The same
may be said of eruptive fevers and acute rheumatism.

Dysentery, scorbutus, and typhus, as they are known in our classical descrip-
tions, form morbid groups totally distinct from each other, and, thus isolated
and simple, are easy of recognition. But when they are combined and com-
plicated with each other, forming, as so often observed in army practice, com-
pound diseases, the pathological problem becomes very complicated. Dysentery
presents the characters of scorbutus, the scorbutic exhibit 'the delirium of
typhus or sink under dysenteric discharges, while the subjects of typhus suffer
from dysentery and become scorbutic. At Constantinople, almost all the grave
cases presented these complications, and it was only exceptionally that the part
due to each affection could be assigned. Usually, the signs proper to one of
these morbid entities disappeared, and were replaced by others of a less im-
portance. Thus, the characteristic eruption of typhus, so well described by
Jenner, was rarely seen when the typhus was complicated by dysentery ; the
continuous fever, characteristic of it, disappeared also, while delirium, some-
times very intense, persisted; at other times, there were but cephalalgia, ver-
tigo, singing in the ears, and restlessness, without febrile heat. Dysentery
was eminently contagious and engendered typhus. In scorbutus complicated
with dysentery, changes in the gums and hemorrhagic discharges were absent,
and scorbutic pains, ansemia of the gums, and a cadaverous aspect, were the
only signs of scorbutic cachexia. At other times, the symptoms of typhus
were suddenly arrested, and replaced by those of scorbutus in its gravest form.
More frequently, the scorbutus and typhus were combined, and then were ob-
served fever, oedema of the face, sub-icteric colour of the skin, delirium more
intense and more obstinate than in ordinary typhus, and bad gangrene of the
mouth and extremities. So, too, scorbutic dysentery presenting typhus symp-
toms was often met with, and, reciprocally, the typhus of scorbutic patients
offering the characters of dysentery.

The author made a most laborious examination of the cases that came under
his care both in the wards and in the dead-house ; and he reserves most of the
data so obtained for a more detailed publication. On the present occasion, he
confines his attention to the necroscopic results, believing these to be of great
interest as illustrating what has been but little studied — the pathology of armies
in the field during winter.

Among 79 autopsies, the brain or its membranes presented important changes
47 times, viz : 1. In 18 in the pia-mater ; the change consisting in simple oedema
in 15, in sanguinolent in 1, and in purulent infiltration in 1. 2. In 13 there
were changes in the vessels ; these being in an ansemic condition in 10, hyper-
semic in 1, and in 2 the seat of capillary apoplexy. 3. In 33 the substance of
the brain had undergone changes ; there being in 6 well-marked general ramo-
lissement, in 9 well-marked induration, in 10 periventricular ramollissement
with ventricular dropsy, in 2 induration and dropsy of the ventricles, in 4
dropsy without change of the walls, in 1 ramollissement of the walls of the 4th
ventricle, and in 1 abscess of the brain. These lesions were sometimes com-
bined with each other. Thus oedema of the pia-mater and anaemia of the brain
were most frequently observed coinciding with increase of the ventricular fluid.
Many other lesions might have been enumerated if the author had not confined

1857.]

Medical Pathology and Therapeutics.

219

his account to such as were sufficiently marked to be beyond all doubt, and
•were important enough to figure as causes or results of disease. It may be
asked to what morbid influences were these lesions due, inasmuch as none of
the diseases above adverted to give rise to such. At first sight, typhus, which
is always accompanied by perversion of the functions of the nervous system,
might seem the determining cause; but pathological induction teaches us that
the nervous symptoms met with in typhus, as in typhoid and in eruptive fevers,
are not the product of palpable changes in the cerebral substance. Thus, in
typhoid fever, the most intense delirium does not coincide with the most marked
hyperemia of the brain; and, in the torpid stage of cholera, much less injec-
tion is found after death than in the algid period, during which the intellect is
quite undisturbed. Moreover, clinical observation proved that in several of
these cases, in which the cerebral changes were most marked, there had been
neither delirium nor coma, such patients having been among those who had
become emaciated and enfeebled by obstinate diarrhoea. Others, again, dying
in this same condition, with delirium and coma, exhibited the same alterations;
while in a third category were patients who had not suffered long, preserved
their flesh, and exhibited' severe cerebral symptoms, and yet in whom these
appearances were not observable after death. The few times the spinal marrow
was examined, it revealed alterations analogous to those observed in the cere-
bral substance. Not being able to determine the nature of these lesions, the
author contents himself with bringing them under the vague general title of
vices de nutrition, intending thereby to indicate that they completely differ in
their nature from inflammation.

Of the same nature were the lesions of the thoracic and abdominal viscera^
some of which were always found accompanying those of the nervous system.
In respect to the heart, it was observed (in the 79 autopsies) notably reduced
in volume 26 times, its tissue was decoloured or whitish in 23, yellowish in 1,
and in 18 atrophied as well as decoloured. In one case only was the change in
colour accompanied by increase of fleshy tissue, while in 9 there was diminu-
tion of consistence or friability. 31 weighings of the heart in these cases gave
as the mean weight in men from 24 to 35 years of age 53|- drachms, the
highest weight observed having been 73-|-, and the lowest 31| drachms. The
liver, together with some alterations only seen in certain cases, presented others
which, by their frequency and their coincidence with grave lesions of the brain
and heart, acquired a greater importance. In 29 instances among the 79, nota-
ble reduction of volume was observed. The mean weight in 27 weighings
amounted to 413| drachms, the maximum weight being 645, and the minimum
202J drachms. In 4 instances the weight did not reach 278 drachms, and in
12 it did not reach 325 drachms. In the case of the minimum weight, the
reduction of volume was so remarkable as, at once, to challenge notice. In
most cases there was no change in the colour of the organ, it being neither
anaemic nor hyperasmic. Changes were observed in the kidneys 48 times, there
being notable diminution in size and weight in 14 instances, hyperemia in 11,
and increase of cortical substance in 8.

Diseases of the lungs, which are of such frequent occurrence in the hospitals
of garrisons, even when under the best hygienic condition, disappear in part
in camps during winter, when all would seem to favour their production. In
21 cases pulmonary or pleural lesions were noted, 5 only of these being tuber-
cular. Changes in the gastro-intestinal mucous membrane were the most fre-
quent of all the lesions. In two-thirds of the cases seen by the author, i. e.,
in 700 or 800 patients out of 1200, diarrhoea had preceded the morbid conditions
which led to the hospital, the stools in one-third of these having been sanguino-
lent. In 1100 out of the 1200 patients there had been more or less diarrhoea,
either at the commencement or during the course of these affections. The 79
autopsies exhibited changes in the large intestines 63 times, in the small 42,
and in the stomach 38 times. Ulceration in the large intestines, abnormal
follicular development in the small, and small ulcerations in the stomach, were
the chief changes observed. The submucous tissue of the bladder, in 8 out of
45 cases in which it was examined, presented small roundish spots of ecchy-
mosis. The spleen was found enlarged in 24 instances, and enlarged and

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Progress of the Medical Sciences.

[July

friable in 10 ; hut both its dimensions and ramollissement were less than those
observed in typhoid fever.

After noticing the numerous changes in the appearances of the skin, the
author goes on to say that the fatty tissue of the sole of the foot and palm of
the hand, that which forms the cushion on which the ligament of the patella
rests, and that which is found at the tibial extremity of the femur, presented,
in the 79 autopsies, curious alterations 27 times. With a normal condition of
the dermis and aponeurosis, the subcutaneous fatty vesicles were found more
or less highly injected, the yellow colour of the fat being concealed by the in-
jected, or even ecchymotic, condition of the cellular covering. It was not a
subcutaneous ecchymosis, but a little-known, peculiar anatomical condition of
the fatty tissue. The intra-vesicular cellulo-fibrous tissue remained normal, or
rather pale, the fat-cellules being very hypersemic, and sometimes having their
surface covered with minute ecchymoses. The fat contained in the vesicles
remained unchanged. This lesion was sometimes simultaneously observed in
all the regions named above ; frequently it was only met with at the sole or
near the knee, and was always found to be more marked at the sole than in the
palm. The fat, situated beneath the aponeurosis, at the palm or sole, remained
unchanged, and the subcutaneous, or deep-seated fatty tissue, presented no such
appearance. No connection could be traced between this appearance and
typhus, scorbutus, dysentery, or congelations. It is an undescribed specific
alteration, the pathological value of which has yet to be determined. — Gazette
Medicate, No. XL.

16. On the Identity of the Specif c Causes of Typhus and Typhoid Fever. — Dr.
Gibbon read before the Medical Society of London an interesting paper on this
subject.

The object of it was to apply certain tests as to the truth of the two forms of
continued fever met with in Great Britain. The author looked upon the so-
called " relapsing fever" as a remittent or malarious disease — 1st, on account
of the periodicity of its symptoms ; 2dly, from the effect of quinine in promot-
ing its cure. After graphically pointing out the obvious distinctions of the
typhous and typhoid varieties of continued fever, Dr. Gibbon contended that
the contrast, marked as it was in the course, symptoms, and lesions of the two
diseases, would not warrant them in concluding that each distemper had its
own peculiar and distinct exciting cause. The futility of inferring a specific
difference in the nature or cause of a disease from a diversity in the character
of symptoms and lesions was illustrated by the fact that secondary syphilis and
scarlatina frequently manifested themselves in different patients by eruptions,
symptoms, and anatomical lesions of the most diverse description. The author
thought that to some minds presumptive evidence of the non-identity of the
two kinds of fever had been derived from the assumed close analogy that their
exciting causes have to that of measles, scarlatina, and smallpox. It was
argued that because measles and scarlet fever were prior to Dr. Wethering's
essay confounded together as one and the same disorder, therefore it was pos-
sible, and even probable, that before Dr. Jenner's essay, typhus and typhoid
were looked upon as varieties of one disease, whereas they were specifically
distinct. This presumption was erroneous, from the fact that the two classes
of disease were not exactly analogous in their exciting cause, as they undoubt-
edly were in their seat, symptoms, and course ; for scarlet fever and measles
were known only to be propagated by personal infection, whereas continued
fever was generated spontaneously as well as by personal infection. The only
method of settling this important question is that so ably carried out by Dr.
Jenner — i% e., the effect of the exposure of healthy individuals to the typhus
and typhoid poisons ; and if each is found invariably to generate only its own
variety of continued fever and not the other, we must conclude that they are
generically distinct. As the causation of continued fever was a matter beset
with so many fallacies and difficulties, the author contended that Dr. Jenner's
87 outbreaks of continued fever, containing as they did one notable exception
to the theory, were far too few to enable a cautious reasoner to decide against
the identity of the two maladies. To apply the test of experiment to the Jen-

1857.]

Medical Pathology and Therapeutics.

221

nerian doctrine, a great and fair one was narrated as having taken place in the
British Civil Hospital at Smyrna in 1855. Early in February of that year, in
consequence of the infected state of the hospitals at Scutari, 800 sick and
wounded soldiers were sent down from the Crimea to Smyrna. At the time of
embarkation none of these men had continued fever, but suffered from diarrhoea,
dysentery, frost-bite, &c. In consequence of official mismanagement these men
could not be landed from the crowded 4< transports" until several days after
their arrival in the Bay of Smyrna. Typhus of a very virulent type broke out ;
several men died of it, and on February 17th, 1855, 79 soldiers suffering from
it were disembarked. In the spacious wards and well-ventilated corridors of
the barracks that had been fitted up as an hospital this fever spread from bed
to bed throughout the entire establishment. In every instance in which the
Crimean soldiers were affected, the disease assumed the genuine typhus cha-
racter. In Dr. Gibbon's division, which the medical council, with the hope,
vain as it proved, of arresting the spread of the disease, at first set apart for
the reception of all fever cases, 84 men passed through the disease during the
first three months, only 4 of whom had the typhoid variety of the fever, and
these men were attendants, not soldiers, in the Crimean army. The author
was credibly informed, both by the military and the civilian medical officers,
that in all cases where the soldiers were affected, the disease was of the genu-
ine inoculated typhus character. To attend upon these sick soldiers there
sailed from England about the same time, 47 Chatham orderlies, 43 civilian
orderlies, 22 female nurses, 7 laundry women, 16 lady nurses, 4 dispensers of
medicine, and 25 medical officers. What was the result of the direct exposure
of these officers to so genuine an epidemic of typhus ? The typhus and typhoid
continued fever, as we have them in this country, are unknown to the medical
practitioners at Smyrna. The disease they call typhus affects, and is very fatal
to young children, and from what I saw of it, it appeared to resemble the in-
fantile remittent of this country. The hospital attendants on their arrival
were, I believe, in perfect health ; certainly none of them had continued fever.
I would submit to this Society that if Jenner's theory be true, every one of
these attendants who contracted the disease ought to have had typhus, whereas
during the first eight weeks, out of the 47 Chatham orderlies, 22 were attacked
with the epidemic. I myself attended three of them ; they had the " rose-spot"
eruption, the diarrhoea, and other general symptoms which are so characteristic
of typhoid fever. Cf the 43 civilians, 2 contracted fever, one of whom I know
to have had typhoid fever, as well from the symptoms I noted during life, as
from the extensive ulceration of Peyer's glands I found in the ilium after death.
Of the 22 nurses, 7 were attacked, one of whom I saw during life, and examined
after death. She had typhus complicated with meningitis. Of the 4 dispensers
of medicine, 3 were attacked with typhoid fever, the diagnosis in all three cases
I myself verified. One died, and extensive ulceration of the ilium was found
at the post-mortem examination. Of 25 medical officers, one had genuine
typhoid fever, which clearly originated by personal infection. The details of
some of these cases were published in a medical journal in August, 1855, for
the purpose of illustrating the treatment of the complications of continued
fever. The author thought this experiment open to fewer sources of error than
any he had witnessed in this country. Another test applied to this doctrine of
fever was by pointing out that it was inconsistent with other facts and well-
established truths. For- instance, the fact that while there were some cities,
as London, where the two forms of continued fever were equally prevalent,
there were other cities, as Dublin and Glasgow, Paris and Vienna, where only
one form of disease, typhus or typhoid, was found. Again, this doctrine of
non-identity was inconsistent with the fact, that in localities where both forms
were met with, the epidemics consisted of each variety of continued fever.
Again, were the diseases totally different, the cases in which sequence of the
two was immediate ought to have been more commonly met with, for patients
with either disease were often together in the same fever wards and hospitals.
The author had never witnessed a case in which a convalescent from one dis-
ease had contracted the other, and he believed such cases to be exceedingly
rare. One such case is recorded by Dr. Peacock, but as no details of the first
No. LXVIL— July 1857. 15

222

Progress of the Medical Sciences.

[July

fever are given, it being merely stated that it was " regarded as one typhoid,"
and as it is the only case I have read of, I think little, if any, weight should
be attached to it. Dr. Gibbon lastly applied Lord Bacon's test of truth —
" Truth is fruitful, but Falsehood is barren" — and contended that while other
great medical truths, as the discovery of chloroform, the discrimination between
measles and scarlet fever, the recognition of all the varieties of secondary
syphilis, &c, had borne immediate and most precious fruit ; the doctrine of
non-identity in continued fever had as yet produced no good result, not even
the segregation of the cases in our fever wards and hospitals. Whatever good
had resulted from the labours of Louis, Chomel, Stewart, and Jenner, was due
to the recognition of the diseases as varieties of the same, not as different spe-
cies of disease. The author deprecated hasty generalizations from a few
instances, and concluded by remarking, that until the non-identity was clearly
and conclusively established, practitioners would do well to look upon the two
diseases as their names implied, typhus and typhoid, as varieties of one essen-
tial fever.

In the discussion which ensued, it was contended by a majority of the speak-
ers that the distinct characters of typhus and typhoid fever had been clearly
proved by the observation of Dr. Jenner. The result had been not only suffi-
cient to aid us in our diagnosis, but also in the treatment of the two diseases.
The question in some respects might appear to be still sub judice, but all ex-
perience tended to the conclusion that the symptoms observed were character-
istic of two distinct forms of fever, differing in their nature, their symptoms,
their causes, and their treatment. — Lancet, May 16, 1857.

17. Analysis of Fifty-two Cases of Epilepsy. — Dr. Sieveking read before the
Royal Medical and Chirurgical Society, an analysis of fifty-two cases of epi-
lepsy observed by him.

These 52 cases had occurred exclusively under his observation, and the con-
clusions were limited to points with reference to which satisfactory evidence
could be obtained.

Sex. — 24 were females, 46.15 per cent.; 28 were males, 53.84 per cent.

Age. — The following is the distribution of the cases throughout the different
periods of life : Under 10 years, 17 ; from 10 to 20, 19 ; 20 to 30, 4 ; 30 to 40,
4 ; 40 to 50, 7 ; over 50, 1 ; or from infancy to the age of 20 years inclusive,
69.23 per cent. ; from 21 to 40 years inclusive, 15.38 per cent.; from 41 to 55
years inclusive, 15.38 per cent. Arranged according to sex, we find during
the first decennium, 8 males and 9 females; during the second, 12 males and
7 females; during the third, 2 males and 2 females; during the fourth, the
same number of each ; during the fifth, 2 males and 3 females ; during the
sixth, 1 female. The male sex during puberty, therefore, seems to exhibit a
more marked proclivity to epilepsy than the female ; at later periods the ratio
returns to the equality shown to prevail during the first ten years of life.

Causes. — Hereditary tendency could be traced only in 6 cases, or 11.1 per
cent. A definite cause was assigned by the patient or the patient's friends in
16 cases, or nearly one-third of the whole. Among these, otorrhoea is men-
tioned twice ; fright twice ; injury to the head, twice. The cases differ in the
relation they bear to the occurrence of the seizure.

Premonitory Symptoms. — The occurrence of an " aura" is a point on which
observers have expressed different opinions. Comprising under this term all
the premonitory symptoms indicating the approach of a fit, it is noted in 27
out of 52 cases ; the most common was a sense of giddiness and impairment of
vision ; sometimes the patient suffered pain in a definite region of the body, or,
though unable to explain the sensation, is aware of some change, from which
they know that a paroxysm is about to take place. The sensation was never
described as a puff of wind or aura in its verbal sense.

Individual Symptom s. — Headache is a very frequent concomitant of epilepsy.
It was observed in 33 out of 52 cases, or 63.42 per cent. The mode of its
occurrence varies ; the patient either suffers habitually or very frequently from
it, and the symptom bears no immediate relation to the paroxysm ; or the
headache occurs shortly before the fits, so as to usher them in ; or again, it

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Medical Pathology and Therapeutics.

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affects the individual after they are over. It was constant or frequent in 36.5
per cent.; it occurred before the fits only in 7.7 per cent.; it occurred after the
fits only in 17.3 percent. Biting the tongue is justly regarded as an important
corroborative symptom ; but it is by no means uniformly present, nor does it
constantly occur in the different paroxysms affecting the same individual. The
tongue was bitten in 17 cases, or 32.7 per cent. The urine was tested for albu-
men in 19 cases, and it was found temporarily present in one, permanently in
one. It was also tested for sugar in 14 cases, and this ingredient was not
found once — a result which seems irreconcilable with the observations of Dr.
Goolden.

Results of Treatment. — The author ventured to express a feeling of scepticism
with regard to the positive certainty of any cure of epilepsy. He believed that,
in the majority, no organic lesion, in the ordinary anatomical sense of the word,
was present in the commencement of the disease, and that, in a large number,
none seems to result from the recurrence of the fits. It appears that a diathesis
is necessary to its occurrence, and that this may be suppressed or held in
check ; but whether it may be eradicated is a question which he would not
venture to answer in the affirmative. He was satisfied of the power of well-
selected remedies in repressing, and often indefinitely postponing, the parox-
ysm, and he particularly insisted on the importance of dietetic and regimenal
treatment. The number of apparent cures was 15, or 28.85 per cent.; in other
instances, more or -less benefit was obtained. The duration of the disease
before treatment is commenced, has an obvious influence over its curability.
Eight of the 15 (apparent) cures were wrought in cases that had lasted one year or
under, four were of two years' duration, one of three, one of six and one of eight
years. The treatment had varied with the nature of the constitutional affection
in each case ; but he was able to draw this general inference, that the main
indications which should guide us, are to remove local irritation by counter-
irritants, to promote the healthy action of the secernent organs, aud to give a
tone to the constitution by vegetable and metallic roborants. The author ex-
pressed his belief that there was no specific for epilepsy ; the salts of zinc
certainly fail to remove it in many eases.

In a postscript he detailed the results of an analysis of the returns of the
Registrar-General with reference to sex in deaths from epilepsy during seven
years ; which gave 6729 males, and 6149 females, or 52.26 of the one sex to
47.73 of the other.

Dr. Webster observed that epilepsy was upon the increase in this country,
many more persons dying of it now than formerly. In London the deaths
were at the present time double the number of those twelve years ago. Hence
it was of the utmost importance to ascertain whether the disease could be
cured, and if so, by what means. In the populous towns in Scotland the dis-
ease was not one-third as fatal as in England. The frequency and fatality of
the disease increased in going south, while insanity prevailed most in the north,
being more common in Scotland than in England. Males, on the whole, were
more frequently attacked with epilepsy than females. In early life the pre-
ponderance was in the female sex; in middle age the disease was about equally
divided, and in advanced life it attacked males much more frequently than
females. Fright was a very common cause of epilepsy, especially in young
and hysterical females. One of the worst cases he had seen was that of a young
female who was frightened by seeing a " ghost" — a young man dressed up in
a white sheet. He had recently heard of a young lady who was seized with an
epileptic fit from paying a visit to the Chamber of Horrors at Madame Tussaud's
wax exhibition. Later in life drunkenness and dissipated habits were a fre-
quent cause of epilepsy. The disease, he believed, was more hereditary than
Dr. Sieveking's tables would seem to indicate. From the observations of
Esquirol and others, and from his own investigations, he believed that a third
of the cases might be traced to hereditary tendency. In a report of the New
York Asylum it was stated that all the cases of epilepsy admitted during the
year were traced to hereditary influence, or to drunkenness in the parents. It
was only in the early period of life that he thought treatment would prove
beneficial Much had been said of late about various minerals for the cure of

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the disease, but it was now admitted that they had only a temporary reputa-
tion, and were no better than the other proposed remedies. Regulation of the
diet was of the greatest importance in the treatment. He remembered a case in
which the patient ate a hearty supper of bacon, eggs, and greens, which brought
on an epileptic attack in the night, and resulted in death within two days.
Mental excitement was a not unfrequent cause of attack. In the epileptic
department of the Salpetriere he (Dr. Webster) conversed with a celebrated
Italian cantatrice, who became so excited on hearing him speak in her native
tongue about her native place, that she was attacked with a severe fit.

The President, Sir Charles Locock, said the author had omitted to mention
one or two causes which were frequently productive of epilepsy. The first was
dentition. Though he did not consider Dr. Ashburner quite justified in carry-
ing his ideas so far as to extract teeth for the cure of epilepsy, he had seen
many cases in which, after certain overcrowded teeth had been removed, the
epileptic patient had never experienced another attack, though he might have
previously had three or four in a day. Every one, moreover, was familiar
with the number of instances of infantile epilepsy from dentition. Another
very fruitful cause was sexual indulgence, and especially onanism, to which he
believed might be attributed the greater frequency of the disease of late years.
There was a form of epilepsy to which special notice had not been drawn, and
which he had been in the habit of regarding as hysterical epilepsy. It was
confined to women, and observed a regularity of return connected with the
menstruation. It was as baffling a form of epilepsy as any other. The parox-
ysms only occurred (except in the case of great mental excitement) at the
menstrual period. Having been often baffied in those cases, of which he had
seen a considerable number, he had been led within the last twelve months to
try a remedy, which had so far answered his expectation that he thought it
desirable that it should have a larger trial, by being made known to a larger
number of persons. Some years ago he chanced to see. a paragraph in the
British and Foreign Medical Review, giving an account of some experiments
that a German had been making with bromide of potassium. He found that
by taking ten grain doses three times a day for about a fortnight he became
impotent, but upon leaving oft' the medicine his powers returned; he tried a
similar experiment with others, and a similar result was produced. He (the
President accordingly thought he would try bromide of potassium in many-
hysterical cases that he met with unconnected with epilepsy, in which there
was a great deal of sexual excitement and disturbance, attended with various
distressing symptoms difficult to manage; and he found that from five to ten
grains given three times a day had the effect of calming the excitement to a
very marked degree. About fourteen months ago he was applied to by the
parents of a lady who had had hysterical epilepsy for nine years, and had
tried all the remedies that could be thought of by various medical men (him-
self among the number) without effect. She began to take the bromide of
potassium last March twelvemonth, having just passed one of her menstrual
periods, in which she had had two attacks. She took ten grains three times
a day for three months ; then the same doses for a fortnight previous to each
menstrual period ; and for the last three or four months she had taken them
for only a week before menstruation. The result had been that she had not
had another attack during the whole of the period. He had tried the remedy
in fourteen or fifteen cases, and it had only foiled in one, and in that one the
patient had fits not only at the times of menstruation, but also in the intervals.
In answer to Dr. Webster, the President stated that the patients whom he had
treated with bromide of potassium, were all under the age of thirty. — Med.
Times and Gaz., May 23, 1857.

18. On the Curable Stage of Phthisis. — Dr. Edward Smith read before the
Western Medical and Surgical Society, a paper on this subject. The author
having discussed the meaning which should be attached to the term "curable,"
refuses it for this purpose, "as the arrest of the disease, with the return of all
vital functions in every part of the lungs/' He then divided the disease into
three stages, viz : the pre-tubercular ; the tubercular, without destruction of

1857.] Medical Pathology and Therapeutics. 225

tissue, and the tubercular, with destruction of tissue, whether to the extent of
ordinary softening, or of the formation of a cavity. He first considered the
question on the received opinion, that tubercle is the essence and the first stage
of the disease, and showed that as tubercle in anything is a substance foreign
(originally or otherwise) to the cells in which it is found, in order to effect a
cure, it must be removed, and that could be effected only by absorption or ex-
pectoration. In reference to absorption, he considered that theoretically it
might occur, since normal epithelium is probably absorbed after disintegration,
and also various deposits into the air-cells, as from inflammatory or congestive
action. To determine this practically was most difficult, since it would be
necessary that further depositions should also be prevented, and to find a case
exhibiting true arrest of the disease, with absorption of the deposited matter,
was of extreme rarity. The author had seen many cases in which the vital
capacity had not only not continued to decrease, but had considerably increased.
But this might only show that tubercle had been removed, and not necessarily
that it had been removed by absorption. As a rule, whether the power of ab-
sorption exists or not, the deposit usually continues to increase ; and hence, if
it do exist, its influence must be counteracted by the continuance of new depo-
sitions. On the whole, the author believed that absorption of tubercle in the
lung may occur, but is not to be expected. In reference to the expectoration
of tubercle, he could not conceive of the existence of a cavity without the ex-
pectoration of tubercular matter at some period, since the existence of a cavity
implied the reopening of a communication with the bronchus, and the removal
of the contained matters. At this period the tubercle would be degenerated
and disintegrated, and hence be more readily recognizable; but since the
expectoration of it would occur commonly, with undoubted signs of the pre-
sence of phthisis, its determination would be of great value in only a very
small section of cases. The elimination of tubercle in a mass was referred to,
and certain masses exhibited which would commonly be called tubercle, but
which had been expectorated by a patient having rather the evidences of
chronic bronchitis. In order to their expectoration from the air-cells, it was
deemed necessary that there should have been an advanced stage of destruc-
tion, at least over a small area, since the masses were too large to have passed
through the minute termination of a bronchus, as it enters the air-cells. The
persistence and progress of the disease, in defiance of these two modes of
removal of tubercle, were stated to be due to continuance of deposition, and
that at a rate, and in a field more extensive than the elimination. The subject
of the arrest of phthisis was not discussed, but it was fully admitted that true
arrest does often occur, and in summing up the whole question, he was of opin-
ion, that if tubercle is to be considered as the essence, and the first stage of
the disease, a cure may occur, but is not to be expected, and cannot be brought
about by any procedure which is admitted to have a fixed and known relation
to the cure.

The author then discussed the nature of the first, or pre-tubercular stage,
and showed that in it there was nothing either theoretically or practically
which should render it less curable than other diseases, provided the patient
could be placed under circumstances as favourable as are required for the cure
of other diseases. The evidence of it were those of lessened action of the air
vesicles, without the presence of any abnormal material, viz : short and feeble
inspiratory action, feeble vesicular murmur, with slight increase of bronchial
sounds; lessened mobility of chest; dulness on clavicle in the degree com-
monly found in chronic bronchitis, and lessened vital capacity and tidal air ;
and he stated these evidences to exist, only varied in degree, in all cases of
predisposition to phthisis. The only change in these signs effected by the de-
position of tubercle is to intensify them, and to add prolonged expiration, wavy
respiration, or other signs indicative of local obstruction to the entrance and
exit of the air; and hence he regarded it as a question of degree, and of
future rapidity of progress. In reference to the diminution of the vital capa-
city at the earliest moment of deposition of tubercle, he showed that it was
inconsistently great in relation to the quantity of tubercle, and must, in great
part, be due to some other cause, that other cause being the lessened action of

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the air-cells. He did not discuss the whereabouts of the power by which inspi-
ration is effected, but mentioned the conditions on which that act must depend,
and as of these he believed that there was no defect in the expansibility of the
thoracic walls or of the expiratory act, the defect must be in the permeability
or tonicity of some part of the respiratory apparatus, or in the call for air, or
in the inspiratory muscular power. He deprecated the continuance of the dis-
pute as to the existence or non-existence of tubercle in doubtful cases, on the
ground that if there be a pre-tubercular stage, the disease is still phthisis, and
in practice ought to be so regarded. In the immense majority of cases there
is no practical difficulty in distinguishing the pre-tubercular from the tubercu-
lar stage ; for, on the one hand, the lessened action is not so advanced, and on
the other, the quantity of tubercular matter gives unmistakable evidence of
the presence of a solid material. The period of difficulty is when the lessened
action is considerable, and the amount of tubercle very small, a period seldom
of long duration.

In reply to various questions, the author admitted that the sole difficulty in
affirming the existence of the pre-tubercular stage, was in proving a necessary
connection between that state of system which is universally admitted as pre-
disposing to tubercle, and the subsequent occurrence of the tubercle; for if
this were done, it would be easy to prove or disprove the correctness of the
author's description of that stage, and to admit that this early condition must
be regarded as an integral part of the disease. The author insisted upon this
connection on the following grounds: 1st. That tubercle, as a morbid material,
must have a cause and a period in which the changes which produce it exert
their influence. 2d. That it has always been admitted that there is a state of
system, and that both original and acquired, in which the occurrence of phthisis
may be prognosticated ; and since this amount of connection is so constant as
to be admitted, it would be a fair deduction that the former was a cause of the
latter. The duration of this condition of system may be long or short, often
indeed from birth, and commonly for years; but the disease itself after the
deposition of tubercle is of the most chronic kind, and hence the long duration
of the first or predisposing stage maybe at least as long, and even much longer,
without lessening the probability of a connection between the two. It would
not follow that all persons having the predisposing state of system should sub-
sequently have tubercle in the lung, since they might die before the period had
elapsed during which tubercle is commonly deposited, or the predisposition
might be lessened by favourable circumstances. Then 3d. The connection be-
tween these stages was proved by the identity of the evidence before and after
the deposition of tubercle, except such as would be due to the deposit of a
solid material and to secondary changes. The essence of these is the lessened
vesicular action of the lung, as evidenced by the spirometer, the form of the
chest, the chest movements, and the respiratory sounds. At the earliest mo-
ment of deposition of tubercle these signs are disproportionately great in refer-
ence to the quantity of tubercle, showing that they are not altogether due to
the tubercle, and they exist before the deposition of tubercle.

19. Diagnosis of Apneumatosis {Pulmonary Collapse). — Dr. Graily Hewitt
read before the Medical Society of London a paper on this subject. In the
first part of the paper, a brief resume was given of the present state of our
knowledge respecting that change in the condition of the lungs, formerly de-
scribed as " lobular pneumonia/' and here alluded to under the designation of
apneumatosis, and the connection of that change with inflammation of the
bronchial mucous membrane. It was shown that the pathological danger, con-
sisting essentially in collapse of the air-cells of certain lobules of the lungs,
is observed almost constantly in the lungs of infants and young children dying
from bronchial affections. It being a fact, that one-third of the mortality in
the second year of life arises from affections in which the bronchial mucous
membrane is implicated, the importance of diagnosticating the presence of
what may be considered the fatal element in these affections — apneumatosis,
was quite evident. The effects produced on the system generally by the super-
vention of this condition, involving, as it must do, a serious diminution in the

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Medical Pathology and Therapeutics.

227

degree of the respiration, were then briefly described. The general symptoms
observed in particular cases, so far as they are diagnostic of the presence of
apneumatosis, were then considered. Children of weakly constitutions are
particularly liable to be attacked with that form of bronchitis in which, as a
sequence, apneumatosis takes place. In such cases the febrile stage of the
bronchitis is of brief duration, and a state of prostration soon ensues, charac-
terized as follows: The skin becomes pallid, or dull and shrivelled; its
temperature sinks. The dyspnoea is aggravated, but altered in character ; the
breathing is very shallow; the rhythm of the movements " expiratory/' very
little air entering the chest at each inspiration. The pulse is very weak ; the
eyes half closed; the lips blue; the cough is extremely feeble. This is a
typical description of the symptoms in cases where apneumatosis has followed
bronchitis; but many modifications of these are observed in different cases.
The shallowness of the respiration, the peculiar kind of dyspnoea, and the
pallidity of the skin, were considered as diagnostic signs of great value. There
was a great resemblance afforded by the condition just described and that of
the cold-blooded animals, the respiration, physiologically considered, being in
both cases small in amount. The congenital condition described by Jorg as
atelectasis differed from apneumatosis, inasmuch as the latter change occurred
after birth, and affected portions of lung which had once been properly aerated
although the two conditions otherwise resembled each other. The differential
diagnosis of atelectasis and apneumatosis would be based on a consideration
of the history of the case in question.

The diagnostic data derived from a physical examination of the chest next
formed matter for deliberation. The diagnosis of a chest affection in early
life, the physical signs alone being considered, was shown to be by no means
easy. By inspection of the chest in cases of apneumatosis, the ribs at their
junction with the cartilages, and the cartilages themselves, are observed to be
drawn in during inspiration ; the lung does not expand, and the descent of the
diaphragm produces a falling in of the thoracic walls at their parts which are
the most yielding. At a point two inches below and outside the nipple, the
walls most readily give way to atmospheric pressure. The antero-posterior
diameter of the chest is then increased, the transverse diameter diminished.
Retraction of the chest walls is in conjunction with certain symptoms, of value
in a diagnostic point of view. It is not observed to so great an extent when
emphysema to a notable degree exists, a circumstance which is not uncommon.
Percussion gives occasionally information of great value, although the irregu-
lar manner in which the apneumatic portions are scattered over the surface of
the lobes renders it often difficult to establish the existence of a marked degree
of dulness. Auscultation shows absence of respiratory murmur when the
portions of lung affected are of considerable extent. There is generally heard,
however, a rhonchus, which has a somewhat grating character. Khonchi
more or less fine are also usually discoverable, but the fine crepitus of true
pneumonia is not heard. The respiratory murmur is often bronchial in cha-
racter over the affected portions. The absence of continued and persistent
heat of skin, as well as of the true pneumonic crepitus, distinguishes cases of
apneumatosis from cases of pneumonia, in addition to which the rarity of this
latter affection in early life affords evidence of a presumptive nature against
its being present in a particular case. The history of the case will in most
instances be sufficient to distinguish apneumatosis from tuberculization of the
lungs. The remarks now offered as to the diagnosis of apneumatosis were to
be regarded as suggestive only, a larger experience being necessary in order to
do more than indicate the general principles on which the diagnosis in ques-
tion is to be arrived at. The chief points alluded to in the paper were illus-
trated by means of drawings of the lungs of patients who had been under the
author's observation during life. — Lancet, March 28, 1857.

20. Rupture of the Heart. — Dr. O'Ferrall exhibited to the Pathological
Society of Dublin (Feb. 7, 1857), a drawing and preparation illustrative of a
variety of rupture of the heart, which, in his opinion, has not been before de-
scribed. The lesion consisted in fatty degeneration of the anterior coronary

228

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[July

artery ; rupture of one of its branches ; injection of the cellular tissue, form-
ing a clot round the vessels and nerves ; and, finally, rupture of the serous
covering of the heart.

The case was that of a man fifty-five years of age. His friends stated that
for the last two years he looked pale ; but his habits of exercise continued
uninterrupted until two days before his death. At this time, not feeling so
well as usual, he -stayed in bed, and took some aperient medicine. On the
day of his death he was lying in bed, at about 10 o'clock in the morning, talk-
ing cheerfully with his friends ; soon after his breathing was remarked to be-
come frequent ; he, however, made no complaints, nor did he mention anything
of his sensations to his friends. The dyspnoea rapidly increased, and at length
(almost suffocated) he started up in the bed, his face flushed, and his eyes
having a staring expression. He cried out, "Take me out of bed V7 " Pat a
blister on my chest V "Open the windows !" And after other expressions
of distress the pallor of death overspread his features ; he was lifted back into
bed, and in a few minutes expired.

On opening the body after death, and slitting up the pericardium, a rent two
inches long was perceived on the anterior and upper surface of the heart,
along the line of the septum. The edges of the rent were separated about
half an inch, and between them projected a firm clot, the upper and lower
portion of which were the colour of dark venous blood ; the middle had the ap-
pearance of fibrin. The heart was then carefully removed for further exami-
nation. On opening the cavities the right auricle and ventricle were found
overdistended with dark fluid blood ; the left cavities were perfectly empty.
There was no communication whatever between any of the cavities and the
ruptured surface of the heart. The substance of the heart itself presented
the tawny colour of what is termed fatty degeneration, and was so soft as to
be lacerated by the slightest force. A probe passed into the anterior coronary
artery, went down through the clot, and showed that the trunk of the vessel
was intact. Very careful dissection demonstrated one of its branches ruptured,
and presenting an open mouth in the middle of the clot ; the texture of the
artery and its branches was so brittle, that the slightest force broke them
down. The aorta was remarkably thin, friable, and presenting a layer of
steatomatous matter beneath its lining membrane. The valves were all per-
fectly healthy. There was no blood in the pericardium, but there was about
two ounces of serum, which had scarcely a sanguineous tinge. Dr. O'Ferrall
said that various forms of rupture of the heart had been described, viz :
perforating rupture ; interstitial rupture (or the " cardiac apoplexy" of Cru-
veilhier) ; and rupture of aneurism of the coronary artery. The case now
presented exhibits the rupture of a branch of the coronary artery, without any
previous aneurismal formation ; and caused by the peculiar degeneration of
the coats of the vessels which, when occurring in the brain — as described by
Mr. Paget — occasionally gives rise to apoplexy. All these ruptures of the
heart appear to be connected with one common lesion, that degeneration which
has been called fatty, but which he would prefer terming lardaceous or oleagin-
ous degeneration, in order to leave the term "fatty heart" for that condition
which consists in a deposit of fat on the surface of the heart, and which he had
sometimes found in combination with a considerable degree of firmness of the
muscular fibre beneath it.

The Dublin School has done much in elucidating this subject. Dr. Kobert
Adams took an early and efficient share in this inquiry, and since that time
Professors Smith and Stokes have enlarged the sphere of our knowledge.
The manner in which it destroys life was well explained by the specimen be-
fore the society, when taken in connection with the history of the brief struggle
which preceded death. A heart weakened by oleaginous degeneration, and
performing its functions feebly, becomes suddenly embarrassed by the pressure
of a coagulum upon the vessels and nerves supplying its right side; thus a
partial paralysis of the right side of the heart is produced ; and these cavities
contracting feebly or not at all upon their contents, become over distended
with blood, as was found in this case. This condition may be supposed to be
connected with the symptoms of suffocation, and suffusion of the face, which

1857.]

Medical Pathology and Therapeutics.

229

marked its first stage. The right side of the heart ceasing to propel the blood,
the systemic vessels must of course become gorged; and the. countenance most
probably, at that moment, indicated this condition. The dyspnoea is easily
explained. Then comes the secondary consequence of this ovbr-distension of
the right side, viz : the want of arterial supply into the left side of the heart.
The left side of the heart not receiving its usual quantity of blood, the brain
must consequently cease to have its necessary supply ; and here comes the ex-
planation of the sudden pallor and death by syncope.

It is probable that the hemorrhage took place so slowly as to allow a coagulum
to form before the serous membrane gave way, and this circumstance, together
with the fact of the hemorrhage having occurred from a small branch, would
account for the absence of coloured blood in the pericardium. Dr. Robert
Adams, in the Dublin Hospital Reports, has alluded to this paralysis as a conse-
quence of deficient supply through ossified or calcareous coronary arteries. It
is probable that in the present case the pressure of the clot upon the vessels
and nerves occasioned a deficient supply, both of nervous influence and arterial
blood, to the right side of the heart. The present case is therefore remark-
able as explaining, by its morbid anatomy, the brief series of phenomena that
occurred before death; and as adding one more variety of rupture of the heart
to those already described. — Dublin Hospital Gazette, April 1, 1857.

21. Diabetes and Saccharine Conditions of the Urine. — Dr. A. B. Garrod con-
cludes the Gulstonia lectures before the Royal College of Physicians which,
this year, were delivered by him with the following summary of the effects of
treatment . —

" To sum up in a few words my opinion of the effects of treatment in dia-
betes, I may remark, that I consider attention to diet of the utmost importance ;
and, without this, I believe that other means are almost, if not entirely useless.
In certain stages of the disease, the diet is advantageous in proportion to its
freedom from amylaceous or saccharine matters ; the nearer it can be obtained
free from these, the greater is the benefit likely to accrue to the patient. The
nitrogenized matters should not be excessive in quantity, at the same time that
due allowance must be made for the inability of the patient to assimilate amy-
laceous principles. In consequence of the appetite being generally above the
healthy standard, and also to prevent the disgust which a rich animal diet is
apt to produce, it is most desirable to introduce certain non-nutritive materials
into the diet, which give bulk to the aliment, satisfy the hunger, and, at the
same time, make the azotized and fatty matters more palatable and acceptable
to the patient. To effect this, I know of nothing equal to the bran bread I
have shown you to-day. In addition to the bran or gluten bread, I consider
that certain green vegetables, as water-cress, greens, and lettuces, may be ad-
vantageously allowed in small quantities; as a diet quite free from vegetables,
if continued for any length of time, will inevitably lead to the production of
scorbutic symptoms. v

The liquid portion of the diet should also be kept as low as possible; and
diabetic patients often derive much comfort from holding small pieces of ice
in their mouths, instead of drinking copious draughts of water. The washing
out of the mouth, also, with cold water sometimes effects the same object. Al-
coholic liquors should be used sparingly ; perhaps the best is a little good
bitter ale, or small quantities of pale brandy freely diluted.

With regard to the administration of drugs, I believe that in many cases
but little advantage is derived from them ; if, however, the nervous system is
irritable, small quantities of opium may be useful; if there is any anaemia,
iron preparations, as the metallic iron in the form of the fer reduit, or the am-
monio-citrate or phosphate of iron should be administered; and if the skin
remains harsh, ammonia salts in small doses, combined or not with other
remedies, as the warm bath. If the emaciation be great, or phthisis threaten,
cod liver may likewise be used; for, although I have shown you that these
drugs, when given in large doses, and for a limited period only, produce no
sensible diminution of the saccharine secretion, yet we may regard it as a fact,
that everything which leads to an improvement in the health, by removing any

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other abnormal state that may be present, tends, in the long run, to ameliorate
the diabetic condition ; hence great advantage is derived from change of air
and scenery, relaxation from business, and other such hygienic means, espe-
cially the avoiding of cold east winds, the use of the flesh-brush, and warm
clothing. I have said that in certain cases I believed that weak alkaline
drinks, as the Vichy waters, or alkalies given in other forms, are occasionally
of advantage, especially if the functions of the liver be disturbed, or any
amount of irritation of the stomach be present." — British Med. Journ., May 16,
1857.

22. On the Prevention of Constipation. — Prof. Phcebus, of Giessen, refers
habitual constipation to the following causes, which may either act separately
or in combination : —

1. The too spare employment of articles of diet which promote the action of
the bowels. Among these water is to be placed in the first rank. Either from
its not being of convenient access, or its quality being bad, this drink is taken
by many in insufficient quantity. In sedentary occupations the sensation of
thirst is too seldom excited, and the habitual frequency of such sensation may
become much diminished if the satisfaction of the call be neglected. To this
class of aliments also belong fruits, salads, sour milk, honey, and fat. Many
country people, who sell all their produce, eat little of these things except
salad ; and the poorer inhabitants of towns often get them only in insufficient
quantity. Those persons who can procure them usually eat salads and fats in
too small quantities ; sour milk easily excites diarrhoea, fruits may cause flatu-
lence, and honey is not always obtainable good. 2. Too little bodily exercise.
3.' Want of exercise of the powers of the large intestine. This is the most
influential of all the causes. It is an error to suppose that the power of the
will extends only over the sphincter; for it prevails much higher, only it re-
quires considerably more time for its exertion. Several minutes, or a quarter
of an hour, may be required to initiate the evacuatory movement, and the un-
initiated may fail altogether in the attempt. By exercising it, we increase the
disposition of the intestine to act, but, under any circumstances, this is rarely
the case in less than five minutes. By paying attention we may plainly feel
the intestinal movement, and convince ourselves that it is independent of the
action of the abdominal muscles : for although the action of these muscles gives
the first impulse to the movement, they contribute little or nothing to its pro-
gress.

Numerous are the remedies which have been recommended for constipation ;
but the action of medicinal substances in so chronic an affection may easily
become prejudicial; and especially such as exert a chemical or functional
action, such as the salts or drastics. In the great majority of cases no other
means are required than those indicated by the above-mentioned causes. The
commonest of these is the want of exercise in the large intestine. If a stool is
desired, the patient must earnestly practise the necessary gymnastic, which
consists in alternate movements of the rectum as during actual evacuation,
and in rapidly drawing in and then expanding the abdominal muscles. Such
movements may be commenced in the chamber and completed in the closet,
several minutes, a quarter of an hour, or even more, being required. If evacua-
tion has commenced, but has not proved productive enough, the movements
must be continued, the person making a firm resolution not to quit the closet
until the aim has been completely attained. The movements are, in fact, the
same as those normally employed ; but they are more rapid, and continued
for a longer time. Kneading and rubbing the abdomen, recommended by some,
are also useful, but as a general rule they are quite unnecessary ; and may be
reserved for those who are not able to follow the above directions, such as
children, insensible persons, &c.

As a general rule, an adult should compel a stool everyday; and the author
does not agree with the statement that some individuals may be content with
fewer, believing that such constipation often aggravates morbid conditions. In
from four to eight weeks, and without the necessity of observing the same
hour, a complete mastery may be acquired over the intestine, so that a stool

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Medical Patlioloyy and Therapeutics.

231

may be always secured once in the twenty-four hours. Although this is the
most powerful agency in overcoming habitual constipation, and will succeed
alone, yet it acts more efficiently when conjoined with articles of diet favourable
to an open state of the bowels. A larger quantity of water will be more easily
drank if at first carbonic acid gas be added. An adult, daring winter, should
take from sixty to eighty ounces daily (deducting from this the equivalent of
any artificial drinks he may take), a larger quantity still during great bodily
exertion, and from one and a half to twice the quantity in summer. When raw
fruit gives rise to flatulence, it maybe taken cooked with spices, and especially
when dried and cooked. With greater regularity of stools, also, flatulence
becomes less, the food being retained for a less time within the canal. Other
articles of diet, as salads and fat, should also be taken in moderation. Exer-
cise, whether on horseback or foot, if continued, is of great service ; but it
exerts no sudden effect, and at first may even induce constipation.

Trying the plan upon himself when a student, the author has, during his
twenty-eight years of practice, recommended it to an immense number of per-
sons, and in the great majority of cases with complete success. For himself
he has attained the power of procuring a daily stool at any convenient time
between four o'clock A. M., and mid-day, the average time required being a
quarter of an hour. Only on one occasion during thirty years has he failed in
his object. Where it fails it is from the want of the necessary strength of
purpose. The plan is not so suitable for the aged ; and is inapplicable to
women during advanced pregnancy, or in organic disease or prolapsus of the
uterus. When from insufficient perseverance the means does not succeed, cold
water clysters form the best supplement; and, exceptionally, salt and oil, with
chamomile tea, &c, may be thrown up. The author never gives purgatives by
the mouth in chronic constipation, believing it to be most impolitic to irritate
the stomach and small intestine, disturbing chylopoesis, and introducing into
the blood materials that are always more or less injurious. — Med. Times and
Gaz., May 23, 1857, from Prdg Viertaljahr, Bd. lii.

23. Lactic Acid a Remedy for Dyspepsia. — A remedy which has for a long
time been used by Dr. Nelson, of Birmingham, and subsequently by many
French physicians, under the name of Pepsine, for the cure of dyspepsia and
other functional derangements of the stomach, has within a short time been
prescribed freely by some physicians in London. It has been very favourably
noticed by Drs. Ballard and Sieveking. Dr. O'Connor has also tested its value
in those cases in which it has been recommended, but not with the success
attributed to its use. He was led subsequently to have recourse to lactic acid,
a remedy which he believed likely to be more beneficial in those affections of
the stomach in which the so-called pepsine has been administered. Before
using the acid internally, Dr. O'Connor, we understand, in order to test its
digestive powers as compared with pepsine, placed an equal weight of animal
fibre, in equal proportions of pepsine and lactic acid, in separate vessels, in an
equal temperature, when he found that the fibre in the lactic acid was reduced
to a pulpy state in a very much smaller space of time than that which was put
into the pepsine. After this experiment, which he thought sufficiently conclu-
sive of the superiority of the lactic acid as a promoter of digestion, he had
recourse to its use as a remedy in those affections of the stomach before alluded
to. The great number of patients with affections of the stomach presenting
themselves among the out-patients of the Royal Free Hospital, afforded an
extensive field to Dr. O'Connor for testing the efficacy of lactic acid in dyspeptic
conditions. After a trial in over fifty cases, he considers that the good results
following its use fully justify him in recommending it as a valuable agent. It
is very necessary to be sure that the lactic acid prescribed should be of chemical
purity, and of uniform strength. The dose varies from half a drachm to two
drachms or more, in infusion of colomba, or a little cinnamon-water. It should
be taken during a meal. The lactic acid found in shops is not generally pure ;
that which Dr. O'Connor has found to be most efficient, from its greater purity,
is prepared by Mr. Bastick, of Brook Street, Grosvenor Square. — Med. Times
and Gaz., April 25, 1857.

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24. Creasote in Erysipelas. — Dr. Delarue strongly recommends the following
application in erysipelas, which he believes exerts even a specific effect upon
the disease : Creasote 8 parts, lard 30 parts, to be applied to the parts every two
hours. — Med. Times and Gaz., April 4, 1857.

25. Iodide of Ammonium. — Dr. B. W. Richardson has been using this article
with considerable success. It is soluble in water, and not unpleasant to the
taste, differing from the iodide of potassium in being a little more pungent.
The dose for an adult is from one to three grains.

Dr. Richardson has, at this time, prescribed the iodide of ammonium in thirty-
eight cases, including one of secondary syphilis, four of chronic rheumatism,
six of phthisis pulmonalis in the primary stage, and in a variety of forms of
strumous disorder attended with glandular enlargements. In action, the iodide
of ammonium is in many respects analogous to the iodide of potassium, but its
effects are more rapidly evidenced. It seems in some instances to produce
diuresis, and its influence in the reduction of glandular swellings is exceedingly
well marked and satisfactory.

The iodide of ammonium admits also of external application as a liniment,
with glycerine or soap liniment as the menstruum. Thus applied, it is easily
absorbed. In two cases of enlargement of the tonsils, both of old standing,
and in one of which, the patient being a child, several unsuccessful attempts
had been made at extirpation, Dr. Richardson prescribed half a drachm of the
iodide dissolved in an ounce of glycerine, and ordered the solution to be freely
applied every night over the tonsils with a large camePs-hair brush. The ap-
plication in these cases has now been continued for nearly two months. In the
child, the tonsils, which originally were so large that they impeded swallowing,
and excited a constant cough, have now become reduced nearly to their normal
dimensions, and the symptoms have disappeared. The other case occurred in
private practice, but Ihe results, we have learned, are equally successful. —
Lancet, May 2, 1857.

26. Liquor Sodas Chlorinate as a Local Application in Smallpox. — Mr. John
Gabb states [British Med. Journ., Ap. 4, 1857) that he has found a weak solu-
tion of the liquor sodse chlorinate highly beneficial in the affection of the mouth
and throat in cases of smallpox. In each case in which he has employed it,
the effect has been extraordinary; one washing of the mouth and gargling of
the throat has restored the patient to comfort and ability to speak or swallow
without difficulty. The strength he has used has been a drachm to half a pint
of water. Applied to the skin, it has had the effect of allaying the troublesome
itching ; and he thinks it not unlikely that a much stronger solution, applied
in the earlier stage of the eruption, might be as efficient in preventing pitting
as some other remedies which have been recommended, whilst, at the same
time, it could be more easily used.

Finding the solution so useful in allaying the itching of smallpox, I gave an
old woman, aged 86, who had been for more than twelve months tormented
with pruritus, and had tried various remedies without effect, the same to use
as a lotion. In a few days she came for more, and said she had never used
anything that gave her so much relief.

27. Fumigations of Essence of Turpentine in Itch. — Dr. A. Anselmier extols
this mode of treatment proposed by M. Aube. The patient, on going to bed,
sprinkles on the sheets and the clothes he is wearing thirteen drachms of
essence of turpentine. When he awakes, he is said to be cured. His bed and
clothes are freed from the infection, and the odour of the turpentine is lost in
two or three days.

28. Progressive Fatty Degeneration and Atrophy of the Voluntary Muscles. —
Mr. Leggatt read before the Western Medical and Surgical Society an inte-
resting paper on this subject. He commenced by alluding to the various
monographs and papers hitherto published on the subject, especially that in
the Archives Generales de Me'decine (1850), which contains the history of several

1857.]

Medical Pathology and Therapeutics.

233

cases, partial and general. Dr. Moore [Dublin Medical Journal, 1852), who
published a similar paper. He then passed on to Dr. R. Quain's long note
appended to his paper on Fatty Degeneration of the Heart [Med.-Chir. Trans-
actions, 1850), in which several cases are mentioned in which this disease
occurred. He then passed on to the paper on this subject by Dr. Meryon,
which appeared in Med.-Chir. Transactions, 1852. Many cases are there re-
corded, but the records of the two post-mortem examinations, in both of which
the nervous centres were found perfectly healthy, though the voluntary mus-
cles of the upper and lower extremities were observed in various stages of
fatty degeneration. The only symptom observed had been loss of power, com-
mencing in the lower extremity. Cruveilhier noticed the same disease in
Arch. Gen. de Med., 1853. In all the cases examined the nervous centres were
healthy, but in two the anterior roots of the spinal nerves were greatly atro-
phied,"especially in the cervical region. Hence he considered the disease to
be essentially dependent on this cause ; that the disease is in fact paralysis,
and that the atrophy and degeneration of the muscles are secondary conse-
quences only. Another case was quoted [Brit, and For. Med.-Chir. Review, Oct.
1855), in which the disease was evidently dependent upon chronic arachnitis
of the cord, originating in a fall ; in this case, too, the anterior roots of the
spinal nerves were inflamed, softened, and atrophied.

In his own case his observation of it had extended over above ten years.
The subject of it was male, born in the country, of healthy parents, in 1838,
and removed to London in 1840. When first seen by the author he was strong,
vigorous, and healthy, but in the summer of 1845 he had jaundice, measles,
and remittent fever, the latter severely. After his recovery he became weak
in his lower extremities, and fell frequently in walking. In 1847 he was seen
by Sir B. Brodie, who considered the case as some spinal affection. In 1850
Sir B. Brodie recognized the disease as similar to Dr. Meryon's case alluded
to. The symptoms were loss of power in the lower extremities, some wasting
of the muscles of the thighs, those of the calves remaining firm and large.
The treatment was essentially tonic, with galvanism. No benefit occurred,
the muscular weakness increased, and gradually extended itself to the upper
extremities. The muscles of the face, of deglutition and articulation, were not
affected, nor was the sensibility of the skin. The rectum and bladder were
unaffected, except that during 1849 there was slight incontinence of urine.
His faculties were unimpaired, and his general health was good. He died
from pneumonia in 1856, aged 18. A careful examination was made 28 hours
after death, during which the muscular system generally was found to be
wasted, and the lower limbs much emaciated. The spinal cord was softened
about its middle one-third, but not inflamed. The roots of the spinal nerves
were healthy, and so was the brain, and all the different viscera, except the
right lung at its base, where it was softened. In the cervical and dorsal re-
gions of the back the muscles were healthy, in the lumbar pale ; the inter-
costals were thin, and the diaphragm very pale. By the microscope no inflam-
matory alteration could be detected in the cord or its membranes, but it
showed fatty degeneration in its various stages in the pale muscular structures,
and in some of these fibrous degeneration without fat. In the heart much of
the striated appearance of health was absent, and much of its structure was
undergoing granular and fatty degeneration.

The author then analyzed fifteen cases of this disease, and stated the results
thus — With respect to the brain : in 6 the brain was healthy; in 1 the white
substance was softened; in 1 there was an osseous plate in the arachnoid.
With respect to the chord : in 6 it was healthy ; in 1 partially softened with-
out fatty degeneration ; in 4 the anterior roots of the nerves were not observed ;
in 1 they were inflamed, softened, and atrophied, the cord also being inflamed
and softened ; in 1 they were normal, while the cord was softened, but not
inflamed. He thus considered that the disease in question was not of spinal
origin, in his own case being persuaded that the softening of the cord was
only of recent origin, and not the cause of the paralysis. He also regarded it
premature to advance M. Cruveilhier's theory, that it consisted in atrophy of
the spinal nerves at their roots ; but rather viewed the disease as dependent

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upon depraved nutrition of the muscular system generally. In addition to
wasting and want of power, M. Cruveilhier had described among the symptoms
pain, twitchings, and cramps ; these are described in no other paper. In all,
the general health was good, and the command of the sphincters complete.
The prognosis as to progress and to recovery was always unfavourable. The
treatment, of course, was tonic, with the use of galvanism. The author then,
in conclusion, enumerated the causes, and grouped them thus: 1. Excessive
muscular action and fatigue. 2. Severe illness, and utter exhausting influences.
3. Hereditary tendency (?) This seemed established in Dr. Meryon's and M.
Aran's cases ; though, in the present instance, the author could not trace this
as a cause.

In the conversation which followed, Mr. Brodhurst mentioned a family in
which four out of nine members have been similarly affected: of these two had
died and two survived ; of the latter, one had head symptoms ; of the former,
in one the brain was softened after death, the cord not being examined ; of
the others, one died from apoplexy, one from phthisis, and one from hydro-
cephalus.

Dr. Fuller related three cases in its partial form, affecting the back of the
neck, and the right upper extremity (two cases) respectively. — Med. Times and
Gaz., March 21, 1857.

29. On the Pathology of the Articular Cartilages. — A paper by Thomas
Bryant, Esq., on this subject, was read before the Royal Medical and Chirur-
gical Society (March 10, 1857). The author commenced by briefly describing
the method by which cartilages are nourished, and laid stress upon the point
of their dependence upon the integrity of other structures for their supply of
blood; the consequence of this dependence being well shown in the fact, that
the nutrition of the cartilages is necessarily arrested or perverted upon any
disturbance to the nutrition of the part, upon the integrity of which they de-
pend for their nourishment. The diseases to which the cartilages are liable
were described, as hypertrophy, atrophy, and granular, fatty, and fibrous
degeneration. That hypertrophy might exist under the same circumstances
that induce such a result in other tissues could not be denied, although the
author knew of no genuine case. The cases described as such were associated
with other disease of the joint, and it was questioned whether such a thicken-
ing was not the result of softening, or mere swelling of the tissue, or some
other pathological change. That atrophy of cartilage exists, daily experience
gave positive evidence, occurring either in old or young people, where any of
the requirements for healthy nutrition were defective. Under the head of
granular degeneration, was included the majority of cases of what is called
ulceration of cartilage. The author adverted to the investigations of Professor
Redfern, stating that his own researches had but tended to convince him of
the truth of that writer's conclusions. He then described the microscopical
appearances of cartilage in the various stages of its degeneration, and stated
that the degeneration might primarily commence either in the cartilage itself,
or upon its synovial or bony surfaces ; in the latter cases, the degeneration
being only secondary in the order of events, some diseased or perverted nutri-
tive change in the bony lamella, or synovial membrane, being antecedent to
the degeneration of the cartilage. A case was then given, illustrative of the
dependence of the cartilages for their integrity upon the integrity of those
tissues to which they were connected. It described a small patch of the syno-
vial surface of a cartilage having become degenerate, exactly corresponding to
a patch of inflamed synovial membrane, the other portions of the cartilage
being quite healthy. If this membrane had been ruptured, an ulcer, so called,
would have been visible. The analogy between this process of degeneration
and of ulceration generally was then alluded to, and the author asked if it were
not fair to conclude that the same cause — namely, inflammation, which we
know does produce a normal nutrition in a part, would in other tissues be also
followed by the same series of changes, and that granular degeneration of the
cell structure, whatever that structure may be, is the element of the process
which is called ulceration ? Degeneration of cartilage as depending upon

1857.]

Medical Pathology and Therapeutics.

235

disease of the bony lamella or heads of the bone was then mentioned, and the
different appearances of the cartilage in the different stages of the disease were
then described. Fatty degeneration next claimed attention, and was described
as being constantly found in joints which had been deprived of their natural
function by any cause whatever. The general and microscopical appearances
were then given, and a case illustrative of the subject read. The author then
stated that it was due to this form of degeneration that the rapid disorganiza-
tion of a joint follows upon an accidental attack of inflammation in chronic
diseased joints. Fibrous degeneration was next described, and the different
appearances to the eye and the microscope in its different stages. The con-
nection between this form of degeneration and the calcareous degeneration of
the osseous lamella was mentioned, and also the connection between the fibrous
and granular degenerations, the former appearing to be a more chronic change
of a somewhat similar character. Other changes were then alluded to, not
included in the preceding divisions, such as the deposition of gouty materials
in and upon the cartilages of joints, and the absorption of cartilage, leaving
the porcellanous or dense bony surface of the osseous lamella. A case was
then read illustrating the connection between the bony lamella and the car-
tilage, and demonstrating that the degeneration of the latter and the calcareous
degeneration of the former were produced by similar causes. — Med. Times and
Gaz., March 21, 1857.

30. Unusual and Obstinate Form of Swelling. — Mr. J. L. Milton records
(Edinburgh Med. Journ., May, 1857) the following remarkable and perhaps
unique example of swelling, with which he himself had been afflicted.

" After having long suffered from eczema of the scalp, I was attacked, early
in June, 1855, with colicky pains of the most severe description, which only
yielded to the inhalation of chloroform. To this succeeded a general outbreak
of eczema, accompanied by neuralgia of the right side of the face, chiefly con-
fined to the track of the posterior dental branches of the superior maxillary
nerve, and the whole of the inferior dental. Quinine, steel, croton oil, and
counter-irritation having failed, probably from want of proper perseverance,
chloroform was again resorted to, and, during the succeeding fortnight, was
frequently inhaled several times in a day. It relieved the pain, but left, as
might have been expected, considerable disturbance of the stomach, and con-
fusion of ideas, percaption, etc. On one occasion, chloroform containing cam-
phor was inhaled, which was followed by free vomiting. Large doses of quinine,
with croton oil and galbanum pill, removed any further traces of the neuralgia ;
and, at the suggestion of a friend, I went to reside in a healthy part of Kent,
and commenced a course of mild aperients and tonics for the eczema, which
had all this time remained very bad.

" By the middle of September it had somewhat abated, and my general health
was greatly improved. I was advised not to take arsenic; and, in order to
procure temporary relief from the discharge and pruritus occasioned by the
eczema, I had two or three times applied strong astringent lotions, containing
a large amount of hydrocyanic acid and zinc, without noticing any effect beyond
smarting and arrest of the secretion.

"Just about this time, then (the middle of September), I noticed one morn-
ing, when dressing, a large swelling extending from the inner to the outer side
of the thigh, running just below Poupart's ligament. It was of the colour of
the skin, firm and painless, of a pyriform shape, the broad end being at the
inner side of the thigh, over which it extended full three inches. I was alarmed,
but, on undressing at night, found that it had disappeared. The next morning,
on rising, an unusual sense of stiffness was felt along the upper part of the
left hip. Remembering the phenomenon of the previous day, I examined in
the glass, and was astonished to see a large swelling stretching backwards just
below the crest of the ilium. This time it was red, but painless as before. It
was five or six inches in length, about two in breadth, and raised a full half
inch above the surrounding skin, the margin being clearly defined. This was
quite a new state of things to me, and I watched its progress with no little
anxiety and interest.

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Progress of the Medical Sciences.

[July

" The third day, the left extremity of this swelling had become indistinct,
and the other end began to stretch down the left side of the sacrum ; but, after
a short interval, it took another direction, and on the fourth day there was a
fully formed lump creeping along the crest of the right ilium : it extended but
little more than half way round when it began to lessen, and passed gradually
away. Meantime, a smaller swelling formed over the middle and upper part
of the left thigh, which disappeared in the same way as the others.

" For upwards of three weeks, one or two of these swellings formed every
day about the hips, crest of the ilium, and upper part of the left thigh; the
right thigh not being attacked. Sometimes two occurred almost simulta-
neously ; on one day there were three. In every instance, they appeared in
the same manner and over the same track as those first described, being only
more isolated. From this time they diminished in frequency, and became
more dispersed.

" Towards the end of October, the face was attacked. A hard swelling passed
slowly over both eyes, beginning outside the external angle of the right eye,
and subsiding considerably there before it reached the corresponding point of
the left eye. It ran its course in about eight hours, and then slowly subsided,
but considerable pufiiness remained for several days. Each eye, in succession,
was so firmly closed at the height of the attack, that not a ray of light could be
perceived, even when an attempt was made to open the eyelid forcibly with the
fingers. A few days after, the mouth was assailed, the swelling being much
more prominent. One or two swellings also showed themselves on the legs,
and one or two small ones on the arms. There was now generally an interval
of a day or two between them ; and after a few irregular outbreaks, the disor-
der almost entirely quitted the lower part of the frame to appear with concen-
trated violence in the face.

" Here, after three attacks, the disorder fairly reached its climax on the 11th
of December. About 4 A. M., a swelling commenced with a peculiar sensa-
tion of tension and uneasiness in the left cheek, which soon roused me, and
prevented further sleep. On grasping it with the hand, it felt like a large wal-
nut. It spread with the most surprising rapidity, and by eight o'clock had
reached right across the lower part of the face, which was so swollen as to be
visible like a dark projecting shadow on casting down the eyes. The anterior
surface of the upper lip was protruded horizontally outwards, and firmly
pressed against the nostrils ; the mucous membrane of the lips was shining,
and so tense as to feel as if it would crack. All attempts at articulation were
very imperfect, and though the mouth was not firmly closed, yet nothing could
be swallowed, owing to its rigidity and the total loss of control over the move-
ments of the lips. The swelling was quite defined, ceasing above on a level
with the nostrils, and inferiorly about an inch below the mouth. The margin
rose abruptly from the surrounding skin, and it lay like an oblong tumour
across the face. Thus it remained till early the next morning, when both eyes
were for the first time attacked at once ; in a short time I became totally blind,
and remained so for some hours.

" The photograph exhibited to the Society represents the last and smallest of
the swellings on the face ; it was taken an hour and forty minutes after I first
noticed the peculiar sensation of stiffness. This time the swelling was confined
to the lower lip. I regret much that the figure of some of the larger ones was
not preserved, but the blindness and difficulty of speaking rendered me averse
to leaving my room.

" Three times the throat was affected, and here the swelling reached its
maximum in half an hour. Mr. Wallford, a medical friend whose aid I re-
quested in one of these attacks, said that the posterior fauces presented much
the same appearance as in a bad case of cynanche ; the uvula, soft palate, and
tonsils being greatly swollen. Saliva was poured out in large quantities, and
for some hours the sense of suffocation was almost unbearable, owing probably
to the epiglottis being involved.

" From the 11th of December the number and severity of the attacks steadily
declined, and they finally disappeared on the 14th of March, 1856.

" At no time were these swellings painful, even on firm pressure, to which,

1857.]

Surgery,

237

I may here observe, they did not yield. Some of them conveyed a feeling of
heat to the hand, but, in general, the only sensation remarked was an extreme
stiffness and distension. The skin was, for the most part, unaltered in colour,
though some of the lumps on the arms and legs were of a pale pink, and one
or two on the hip of a bright red. The subsidence of the swelling was never
followed by any desquamation or itching, but on two occasions the skin of the
lower part of the faCe became slightly yellow, and there was a free secretion
of sebaceous matter, which, for some days after, could be peeled off in flakes.

" No constitutional disturbance of any kind accompanied either the outbreak
or decline of these singular phenomena ; nor did they seem to bear any rela-
tion to such aggravation or improvement as occasionally took place in the
eczema. I never succeeded in tracing them to the use of any particular article
of food, though I must plead guilty to an immoderate indulgence in strong-
coffee for some years previous. When once the swellings had begun to form,
no local application, such as vapour baths, hot fomentations, poultices, cold
spirituous lotions, and pressure, exerted the slightest influence in checking
their progress. Mr. Gay and Mr. Skey were consulted. Both recommended
tonics ; and these certainly improved the general health, and possibly, also,
controlled the severity of the symptoms. Mr. Robert Taylor kindly examined
the urine, but found it quite normal ; he, however, advised colchicum and
bichloride of mercury, which seemed to hasten the disappearance of the disor-
der, thus suggesting-some analogy with chronic urticaria. Sir Benjamin Brodie
considered the affection dependent on disorder of the stomach, remediable by
the use of liquor potassae. Diaphoretics were tried, as the skin was always
dry ; but I cannot say that I ever noticed any appreciable effect from their em-
ployment.

" None of these swellings ever formed in the afternoon or evening. All those
of which I noticed the commencement began between four and ten A. M., and,
with one exception, always reached their utmost height in four hours. Those
on the face were generally about a week in subsiding completely ; the others
disappeared almost as rapidly as they came.

" I have thus endeavoured to give a faithful description of the case while it
was yet fresh in my memory, and would gladly learn if any light can be thrown
on the pathology and history of the complaint.

" In the beginning of January last, these swellings again made their appear-
ance in as severe a form as ever, but this time confined entirely to the trunk.
Iodide of potassium, in doses of seven grains, three times a day ; a grain and a
half of the acetic extract of colchicum every night, followed by one-eighth of a
grain of bichloride of mercury, also at night, removed them. This time also
they supervened upon the use of dilute nitric acid, taken in moderate quanti-
ties for about a month previous to the appearance of the first tumour."

SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE

SURGERY.

31. Concussion of the Spinal Cord. — Dr. J. S. Hughes makes some interesting
remarks [Dublin Hospital Gazette, April 15, 1857) on this subject, and adduces
the following example of the accident : —

"L. Whelan, set. 40, a strong, healthy drayman, was admitted into Jervis-
street Hospital on the 15th February, 1857.

11 History of the Case. — Whilst endeavouring to jump up on his dray, which
was in rapid motion at the time, Whelan toppled over, coming to the ground
on the back of his neck with great violence ; he was immediately lifted up by
the bystanders, and conveyed on a car to the hospital, as it was found that he
had no power whatever over his legs. On examination after his reception into
hospital, the following symptoms evinced themselves, viz : There was complete
loss of motion, as well as of sensation, over both of his lower extremities, but
No. LXVIL-July 1857. 16

238

Progress of the Medical Sciences.

[July

he possessed perfect command over his bladder, having made water, of his own
accord, soon after his admission ; intellectual faculties unimpaired ; pulse weak
and quick ; temperature of the legs and feet very low ; no vomiting. A slight
degree of swelling and redness existed at the seat of injury, corresponding to
the fourth, fifth, and sixth cervical vertebrae ; but no evidence of fracture of the
vertebras could be detected. After the patient had been for about an hour in
bed, he began gradually to acquire some feeling in his lower extremities, to-
gether with a return of the power of motion ; but according as he regained the
motive power over his lower extremities, loss of power of motion, but not of
sensation, over his hands and forearms as gradually set in. In four hours
after admission into hospital he had the perfect use of his lower extremities,
but had completely lost the control over his forearms and hands.

" Treatment. — Absolute rest in the recumbent posture enjoined. One dozen
leeches were applied to the seat of injury, and two grains of calomel, together
with one-quarter of a grain of opium, were ordered to be given every fourth
hour.

"20th. Symptoms as before ; mouth unaffected by the mercury. Continue the
pills, and take 12 ozs. of blood, by cupping, from the back of the neck.

" 22>d. The patient now enjoys more power over his left hand and arm, but his
right hand and forearm continue powerless ; mouth slightly under the influ-
ence of mercury ; but he has, during the night, been attacked with mercurial
diarrhoea. Omit the pills ; give chalk mixture and catechu, and rub half a
drachm of mercurial ointment, night and morning, into the axillae ; apply a
blister to the back of the neck, and dress the surface afterwards with Albe-
speyre's issue paper (No. 2).

" March ith. Power over left hand and forearm improved, but the right hand
and forearm remain almost perfectly paralyzed ; mouth slightly affected.
Ordered half a grain of the sesqui-iodide of mercury, in the form of pill, three
times in the day. Electro-galvanism was directed to be applied, daily, from
the region of the neck to the right hand and fingers, beginning at a low power,
and gradually increasing it in strength.

" 12^7i. A progressive amendment has taken place since last report. The
patient has regained complete power over his left hand, and is daily regaining
the use of his right one. The electro-galvanism has been applied each day, as
directed. The iodide of mercury was withdrawn this day, mercurial fetor and
insalivation being present.

"April 2d. The patient is now so far improved, that he can tightly grasp a
small object with both his hands, and he feels so well, in every respect, that ha
is anxious to return home, but has been prevailed on to remain in hospital
for a few days longer.

''Remarks. — Concussion of the spinal cord, independent of fracture or luxation
of the vertebrae, may present varieties, both as to the extent, intensity, and
duration of its symptoms ; thus it may give rise to but a partial and transient
impairment of the powers of motion or sensation, or of both, to parts below the
seat of injury ; it may be followed by complete and permanent destruction of
motive power, and of sensation, of either one or more of the extremities ; or it
may, on the other hand, when affecting the cord above the origin of the respi-
ratory nerves, prove instantaneously fatal. Sometimes, in concussion of the
spinal cord, death ensues at a remote period, from bed-sores and sloughing; at
other times, the patient is carried off by chronic inflammation of the bladder
and kidneys.

" Concussion of the spinal cord, independent of fracture or luxation of the
vertebrae, is not unfrequently accompanied by more or less compression of the
spinal cord, the consequence of either effusion of blood, or of lymph, or of both
(which was probablv the case in the man at present in the hospital) a point of
importance, with a view to the treatment of these injuries.

" The loss of power, in a case of concussion of the spinal cord, will, to a
great extent, depend on the part of the cord injured. Thus, for instance, in
the case of Whelan, at present under our observation, in which the violence
was applied to the region of the neck, but below the origin of the respiratory
nerves, the patient was immediately affected with loss of power and sensation

1857.]

Surgery.

239

over the lower extremities, and, soon afterwards, by paralysis of his forearms
and hands ; but it is an interesting fact, and one of course much in his favour,
that he never lost control over his urinary bladder.

"About two years ago, we had, as many of you no doubt recollect, a Prus-
sian sailor, Kraraoset by name, under our care in this hospital, who, having
on a long voyage at sea fallen in a gale of wind from the main-yard arm of his
ship to the deck on his back, was instantly seized by paralysis and loss of sensa-
tion of the lower extremities, as well as by loss of power over his bladder. In
the Prussian's case, the injury was chiefly confined to the lumbar portion of
the spine, where he was struck, in his fall, by a projecting part of the deck.
Whether in his ease there had been a fracture of one of the vertebrae, was a
matter of speculation, there being apparently the slightest possible projection of
one of the lumbar spinous processes. We kept the poor fellow for some months
in the hospital, at the expiration of which time we sent him to his own country,
through means of the Prussian consul, having regained perfect power over his
urinary bladder, and somewhat improved in his other symptoms, but not mate-
rially so, with a view to his ultimate recovery.

"It is very important to hold in mind, that a severe shock communicated to
the spinal column, may be followed by symptoms very different indeed from
those of concussion or compression of the spinal cord, in proof of which I need
only mention that, about two years or so ago, I was asked by Dr. Kavanagh,
junior, of Kingstown, to see a sailor boy, with him, who had fallen on his head
and spine to the deck, from a temporary gallery, which had been erected round
the funnel of a steamship, and who, as the result of the accident, was, at the
time I visited him in consultation, labouring under all the well-marked symp-
toms of cerebro-spinal arachnitis.

" As to the diagnosis of concussion of the spinal cord, lesions of motion or of
sensation, or of both, to a greater or less extent, and for a longer or shorter period,
over one or more of the extremities, supervening instantaneously on shocks commu-
nicated to the spinal column, are the symptoms that are characteristic of concussion
of the spinal cord ; and where these are completely absent, true concussion of the
spinal cord does not, according to the modern acceptation of the term, exist. Mye-
litis, or spinal arachnitis, which are very different in their symptoms, and which
may result from violence inflicted on the spinal column, must, therefore, not be
mistaken for ccncussion of the spinal cord.

" Now, with regard to the pathology of concussion of the spinal cord, when
opportunities have been afforded of examining the medulla spinalis, imme-
diately, or soon after the receipt of the injury, a highly vascular state of the
cord has been detected ; in some cases the cord exhibiting, on division, a some-
what reddish hue ; in others assuming a yellowish or preternaturally white
appearance ; whilst in others again, apoplectic clots have been found in the
substance, or on the surface of the cord ; whereas, in many of the instances on
record, no morbid appearances whatever presented themselves to the eye either
in or about the spinal cord or its membranes. Thus, Frank mentions four
cases of concussion of the spine, in not one of which could any morbid appear-
ance be detected, either in the vertebrae or in or on the spinal cord.

" We cannot be too cautious in delivering our prognosis in a case of concus-
sion of the spinal cord, inasmuch as it is by no means at all easy to foretell in
what manner a case is likely to terminate ; but we should, as a general rule,
be chiefly guided in forming our opinion as to the likely results, by the follow-
ing considerations, viz : the seat of injury, the extent of nervous lesion, and the
condition of the urinary bladder. The most unpromising cases do, however,
sometimes recover. A man may, on the other hand, apparently completely
recover from the results of concussion of the spinal cord, and yet, after a longer
or shorter lapse of time, become the subject of ramollissement of the medulla
spinalis, as a remote consequence of the injury.

" The chief indications in the treatment of a case of concussion of the spinal
eord are, absolute rest in the horizontal position ; the use of the catheter, when
necessary ; depletion, general or local, according to circumstances ; the admi-
nistration of mercury, so as to bring the system rapidly under its influence ;

240

Progress of the Medical Sciences.

[July

the avoidance of bed-sores ; and the application of electro-galvanism, should
such be deemed requisite.

" Absolute rest, in the recumbent position, is best carried out in injuries of
the spinal column, by the use of one of Earle's beds, by which means the
patient need not abandon the horizontal position, or move his spine, even dur-
ing the action of the bowels.

" With regard to the exhibition of mercury in concussion of the spinal cord,
many prefer calomel ; others the iodides. In Whelan's case, we kept up the
mercurial action for some days, by the administration of half-grain doses of the
sesqui-iodide of mercury, as it has the character of rapidly rousing the absorb-
ents in removing extravasated blood, or lymph, or both, when effused.

" In concussion of the spinal cord, counter-irritation frequently proves use-
ful ; and electro-galvanism may, if used at the proper period, as in Whelan's
case, act most beneficially.

" Bed-sores, which are with much difficulty kept off in concussion of the
spinal cord, where there is persistent paralysis of the lower extremities, are
best avoided by the use of suitable pillows, air-cushions, or the water-bed ; or
by placing the patient on partially inflated ox-bladders. "When bed-sores
threaten, the surface should be painted over with solutions of gun-cotton or
gutta percha in chloroform or ether.

" In conclusion, it is scarcely necessary to say, that the greatest attention
should be paid to the condition of the urinary bladder, in all cases of concus-
sion of the spinal cord ; and that, if necessary, the urine should be drawn off
by means of a catheter, as often as may be required."

32. The Constitutional Origin and Treatment of Cancer. — Mr. Weeden Cooke
presented to the Harveian Society (Feb. 19, 1857) a valuable and instructive
paper on this subject.

The author had begun the study and treatment of this disease at the Cancer
Hospital on the principle of local eradication by operation, but some years of
observation upon upwards of a thousand cases have gradually forced upon him
the conviction, that the whole system must be the first, as it is the most diffi-
cult point of attack — the local disease being comparatively easy of manage-
ment. As to hereditary predisposition, Velpeau says 1 in 3 have this predis-
position. At the Cancer Hospital it has only been noted in 1 in 6, and by
Lebert in 1 in 12 cases. This forms at least a link in the chain of evidence.
According to a calculation made by Mr. Cooke, in upwards of 1,000 cases, the
average age is 43J years. At the Cancer Hospital the female patients are 6 to
1 male. The effect of depressing moral agents has been noted by most authors,
but rejected by some. Sir A. Cooper says, " Three-fourths of these cases arise
from grief and anxiety of mind and the author's experience confirms this
opinion. Material alterations in the blood are brought about under these cir-
cumstances. Atrophy of the red corpuscles and increase of the colourless
globules may be observed, and thus the creative power of the blood is deterio-
rated, and the tissues which this ill-elaborated fluid forms shows that defective
organization which is seen in cancer. Whether the defect be a process of
exudation or of impaired nutrition is a speculation difficult of solution, but Mr.
Cooke leans to the idea of deranged nutrition or degeneration of the tissues,
similar to the fatty degeneration now so fully recognized. In a very large
number of cases there is a period when the cancerous tumor ceases to increase,
begins to diminish and gradually to waste away, so that the prolongation of
life is not in any way affected by the patient having been subject to this malady.
The spontaneous cure of the disease has been noticed by Velpeau as well as
Sir A. Cooper and other authors ; and several cases were recited from among
the patients at the Cancer Hospital. Of all the medicaments which experience
or theory has shown to influence this disease, iron, in its various forms, is
capable of effecting the largest amount of benefit. In order to obtain this
good in various constitutions it is necessary to vary the form of its administra-
tion, and then to alternate this tonic with others. The mineral acids are most
valuable, either alone or in combination with other drugs. Lemon-juice and
sarsaparilla, in delicate people, is a most excellent appetizer. Bark, in the

1857.]

Surgery.

241

form of the compound tincture, is largely used with the greatest benefit at the
Cancer Hospital; and cod-liver oil as an adjuvant to the other remedies is ser-
viceable. Diet and moral management are of the utmost moment in the conduct
of these cases. The system requires to be well nourished, and somewhat
stimulated. Good meat, good beer, and a fair supply of good vegetables, put-
ting aside the nonsense of sloppy soups and leucophlegmatic fish, to waste the
appetite and distend the stomach ; and wine may be taken according to advice.
The treatment of the mind is not less important, and if we could eradicate the
idea of the incurability of cancer we should do much towards its cure. Hope
would assist our efforts at restoration more perhaps than any physical agent.
The diversion of the mind from the contemplation of the malady by the influ-
ence of genial society, by the cultivation of literature and science, and by
change of scene in travel, have tended to the production of that atrophy of the
disease which is in fact its cure. As to the local treatment of cancerous tu-
mors, it appears from the statistics at the Cancer Hospital that 128 persons
have presented themselves who had been operated on previous to coming to
the hospital, and that the average lapse of time before the return of the disease
in these cases was eighteen months. From this it may be assumed with tolera-
ble justice that operations do not generally cure the disease. There are, how-
ever, some cases in which removal of the local malady is desirable, as tending
to prolong life or remove unsightliness. One is, that of the advanced hemor-
rhagic stage of cancer, and the other condition is when epithelial cancer attacks
any exposed part, such as the lips, face, or extremities. The method of re-
moval in either of these cases should be by the knife, under the influence of
chloroform. As to the revival of the treatment by caustics, says Mr. W. Cooke,
" now that we have the invaluable assistance of chloroform, I cannot imagine
how such a necessarily prolonged and painful procedure can be recommended
by the profession, or tolerated by any patient who has the power to select the
least of two evils. The knife can do without pain in as many minutes all that
the caustic can do with pain of no ordinary character in as many days."
These two agents, however, in the local treatment of cancer, are of infinitely
less importance than those which assist in the induction of that atrophy of the
tumor which nature brings about in many cases, and which art may assist in
promoting in many more. Of all the detergent remedies, lead, in its various
pharmacopoeial forms, is the most efficacious. The liquor plumbi, alone or
diluted; the ceratum plumbi and the ceratum saponis, which contains lead;
the unguentum plumbi iodidi, and the emplastrum plumbi, with or without
soap or adhesive plaster, are all, at different stages of the disease, most valua-
ble adjuvants to the general constitutional treatment. It would be tiresome to
enter into details of special applications for particular parts of the system,
such as the chlorate of potash and hydrochloric acid lotion, and carrot poultice
to the ulcerated or sloughing breast ; the borax lotion, and the application of
the nitric acid or sulphate of copper to the tongue, &c. These are matters
which practice teaches, and which may sometimes perhaps be varied with ad-
vantage according to the taste or fancy of the surgeon, provided that the great
principle be at all times kept in view, namely, that local treatment in cancer,
whether by the knife or caustic, or detergent applications, is and must be
second in importance to the general upholding of the constitutional powers. —
Med. Times and Gaz., April 4, 1857.

33. Necrosis of Cancer and its Consequent Enucleation. — M. Moullin read a
paper on this subject before the Medical Society of London (April 25, 1857).
We notice the paper principally on account of the sentiments which the discus-
sion of it called forth, and which we believe to be eminently sound. Mr.
M. premised by giving the history of six cases of cancer of the breast, and
showing several specimens which had been enucleated by the action of the
chloride of zinc. These specimens, the author stated, were positive proof of
the result of a mode of proceeding which, as far as he could ascertain, was
entirely new. The object proposed was not to destroy tumours piecemeal,
making layer after layer slough and separate by successive applications, which
are each brought into contact with an extremely irritated surface, but rather to

242

Progress of the Medical Sciences.

cause the slow death of the morbid growth, by causing its substance to become
day by day penetrated more and more deeply by an agent which coagulates the
blood in its vessels, and acts in like manner upon the living albuminous solid;
and finally, when completely necrosed, to become enucleated en masse, as in
the present instances. The principle which guides the whole proceeding is one
well known and acted upon by all our best practitioners. It is to proportion
the rate of our therapeutic efforts to that of the disease we are dealing with.
In acute disease we must act with energy and rapidity; in chronic, with
sustained gentle perseverance. The morbid action that would be exasperated
by violent measures, yields kindly to a mild influence steadily maintained.
Such, the author believed, was the rationale of the treatment which he fully
described in the history of the cases. Mr. Moullin stated that the essential
point in his plan of proceeding was the mode in which the remedy was used,
and it was quite possible that other remedies used in the same way might pro-
duce like effect, of which we have repeated instances in medicine. The great
step, however, was to gain the leading idea, the guiding principle; details are
easily learned by experience. The history of these cases furnishes us with a
very good illustration of the disease in its various stages, as is seen in the out-
patients' room of our metropolitan hospitals daily. No. 6, of one year's dura-
tion, was in its first and by far the most favourable stage for either plan of
treatment, being about the size of a nut, perfectly movable, and rarely causing
much pain. The disease, the author thought, at this stage might, with all pro-
priety, be denominated local. No. 1, of twelve years' standing, was a very
good example of the disease in its second stage ; the tumour the size of an
ordinary orange, of stony hardness, well defined, yet movable ; pain more of a
lancinating character, as if a needle were run in. Next come Cases 3 and 4,
the one of two, the other of twelve years' growth, where the tumour is attached
to the integuments, having that peculiar appearance previous to the commence-
ment of ulceration, and forming the third stage. Then Cases 2 and 5, the one
of twenty, the other of three years' duration, where ulceration takes place,
presenting an open excavated sore, with hardened, everted, irregular edges,
uneven base, covered with a gray slough, offensive, thin discharge, frequent
losses of blood, and all the usual train of constitutional symptoms. Such was
the history of the cases brought before the society, and it was in such cases
that the plan of treatment proposed would be found most advantageous. The
object of this plan of treatment is not merely to destroy diseased parts, but to
modify the abnormal vitality of the subjacent tissues, without which the disease
will reappear. The effect of the chloride of zinc in cancerous cases has long
been known to the profession, and largely used on the continent, with marked
success, and in this country by Mr. Ure, who, in 1836, brought before the pro-
fession the treatment of cancer by the chloride of zinc. He says: I have no
doubt that a part of its efficacy in eradicating from their ultimate ramifications
cancerous tumours, is to be ascribed in no small degree to the powerful action
it exercises on albumen. In this way, numerous minute points, undiscoverablo
by the surgeon, and inaccessible to his knife, are searched out and destroyed;
for when the chloride of zinc comes in contact with the morbid albumen, ife
gradually penetrates its substance, so as to deprive it of vitality, and to form
an eschar. Without seeking to draw a comparison between the relative merits
of the extirpation of cancer by surgical operation and by the necrosing agent
in question, suffice it to say, that the latter never creates any serious incon-
venience, while an amputation of the breast may not always have the most
favourable issue. The chloride of zinc is found most useful in open or ulcerated
cancers and cancroid growths generally, where the knife is utterly out of the
question, also in the enucleation of tumours that are of a doubtful nature, and
in secondary cancerous formations that take place after operations with the
knife. In the treatment of rodent ulcer, the noli me tangere of some authors,
of which Mr. Moullin related a case (cured by him in eight weeks) of seven
years' duration, which had resisted various other plans of treatment, the author
stated that two important questions presented themselves for the consideration
of the profession. The first is, the possibility of the enucleation of tumours,
malignant or benign, by the action of chloride of zinc. This first point, he

1857.]

Surgery.

243

thought, was satisfactorily proved by placing facts before his professional
brethren, and he would leave it to them to declare whether they were satisfied
with the result. As to the second point, viz., the liability and probability of a
return of disease after enucleation of the tumour, this nothing but time and
experience could decide.

Dr. Mackenzie remarked that the paper could not decide the respective value
of the local treatment of cancer by enucleation or the knife, inasmuch as the
cases related were too recent on which to form any opinion. It was still a
question how far the removal of the local disease did away with the chances of
return. Cases had constantly occurred in which the removal of the local dis-
ease was followed by internal cancerous affections, and had destroyed the
patients. He related a case in point.

Mr. Barwell said that it was questionable whether any local treatment would
so modify the constitutional taint as to prevent a recurrence of the disease. He
wns surprised that there had been so little pain in Mr. Moullin's cases. In
1824, M. Cancoin had used the arsenical paste in some cases with a fatal result.
He then experimented with seventeen different kinds of escharotics, and had
found that of these nitric acid was the least painful in its application, whilst
chloride of zinc was the fourteenth on the list. He (Mr. Barwell) had used
the tannic acid in some cases of cancer. To be of service, it was necessary
that there should be much care in its application. Slits must be made in the
slough to enable, the tannie acid to permeate through it. Applied in this way
it was productive of little pain.

Mr. Jabez Hogg did not feel satisfied with the evidence produced by the
author as to the character of the tumours which had been enucleated by him.
In the absence of a microscopic examination, the diagnosis must necessarily
be imperfect. Numbers of cases were called cancer, treated as such, and said
to be cured, which were in reality benign tumours. He related a case which
had been sent up to him from the country, of supposed cancer of the tongue.
The disease, however, was found to be caused by pressure from decayed teeth.
The teeth were removed, and tannic acid, under the advice of Mr. Barwell, ap-
plied to the so-called cancer, which was perfectly cured in a fortnight.

Mr. Birkett had been quite disappointed in the paper, which contained
nothing new. Escharotics had been extensively employed, to prevent the
natural alarm which patients had on the use of the knife. With respect to
true cancer, no case had been recorded as successful after removal, which was
not eventually followed by death from secondary deposits in some other organs.
It was said in favour of escharotics that they had so much influence on the
surrounding tissues as to prevent the recurrence of the disease, but this was a
mere assertion, and had not a tittle of proof to rest upon. The question at
issue was clearly " caustic versus knife and he contended, in opposition to
the statement of the employers of caustic, that the knife was not uncertain, but
that the local disease could be more safely and readily extirpated by it than by
caustic. He had tried the caustic; it had been also extensively used by Key,
Callaway, and Brodie. Mr. Key had tried it in fifteen or twenty cases. All
the cases had terminated with exactly the same results as if the knife had been
used. M. Cancoin had operated in four cases in this country, and he (Mr.
Birkett) was in a condition to state the ultimate results of these proceedings.
The first case was that of a lady thirty years of age, who had been operated
upon three times by Sir Benjamin Brodie, and twice or thrice by Mr. Turner,
of Manchester. The case was afterwards treated by M. Cancoin, and did not
recur. But it was well known that this was not a case of cancer at all, but was
simply one of adenocele. It was reported, however, at the time as a case of
cancer, and vaunted as a cure of that disease. The other three cases terminated
fatally, just as though the ordinary operation by the knife had been performed.
The cases recorded by M. Cancoin in his work might be divided into four dis-
tinct classes: 1, cases of chronic abscess; 2, cases of ordinary adenocele; 3,
cases of irritable mamma. These, of course, all did well. The 4th were cases
of true cancer, all of which had an unsatisfactory termination. He (Mr. Bir-
kett) contended that the use of the caustic had no advantage whatever over that
of the knife, and he called upon the author of the paper to state explicitly what

Progress of the Medical Sciences.

[July

was the real influence whieh the caustic exerted over the tissues surrounding
the primary growth, so as to prevent a recurrence of the disease.

Dr. Rogers had seen a case which had been operated upon in the Middlesex
Hospital by Dr. Fell. The patient had died, after three weeks of agonizing
torture, from carcinomatous disease of the chest, and effusion. He had seen a
similar case of cancer of the os uteri, but with the same results, under the
care of Dr. Pattison. This patient had died after the most intense agony, eon-
sequent upon the application of the caustic.

Mr. Weeden Cooke believed that the author's plan of slicing and cauterizing
a cancerous breast was identical with that pursued by Dr. Fell. It was a most
painful and severe operation, protracted for thirty or forty days; and, after all
this suffering, did no more than the knife could do in a few minutes, without
any pain at all, with the aid of chloroform. The plan pursued by Mr. Stanley,
at St. Bartholomew's Hospital, was a much more humane and equally efficacious
proceeding; but in Mr. Cooke's opinion, excision by the knife, if an operation
was necessary at all, was the only proceeding that ought to be sanctioned by
the profession. Mr. Cooke, however, considered that operations, whether by
caustic or the scalpel, were undesirable; that the disease was not eradicated by
them, but that the dyscrasia which accompanied the disease was thereby in-
creased, and life shortened. On the other hand, by supporting diet and tonic
treatment, the constitution was enabled to resist the progress of the disease,
and bring about that resolution by atrophy of the tumour which was observed
in so many cases at the Cancer Hospital. Mr. Cooke thought that the whole
profession would eventually protest against this revival of a treatment, painful
in the extreme, and having no single advantage over the usual mode of excision
by the knife. — Lancet, May 2, 1857.

34. Subclavian Aneurism Cured by Displacing a Portion of its Fibrinous
Contents. — In our number for January last, p. 256, we noticed an ingenious
method proposed by Mr. Fergusson for the treatment of aneurism. This con-
sists in displacing a portion of the fibrinous contents of the sac, and directing
them so as to obstruct the dental end of the tumour.

Mr. Eobert Little records {Med. Times and Gaz., May 23) the following
interesting case of subclavian aneurism treated by this plan.

D. M., an albino, aged 53, admitted into the County Donegal Infirmary on
the 6th October, 1855, with an aneurism of the right subclavian artery, gives
the following history of his case : States that, having been in the habit of deal-
ing in eggs and fish, which he usually carried through the country in a basket
suspended on his back by means of straw ropes through which he passed his
arms, he first felt pain in the right arm in the preceding month of March, which
gradually became so severe that in the month of May he was frequently obliged
to sit down on the roadside and remove his burden for a time. Soon afterwards
he discovered a tumour above the right clavicle, directly corresponding to the
site on which one of the ropes pressed, which also became painful after a short
time ; and in the beginning of July he perceived " a beating in the lump,"
which then began to enlarge rapidly. In the month of August he says he had
such a feeling of drowsiness that for a fortnight he slept the greater part of
each day and night, during which time he lost his appetite and took nothing
but milk, and at this time he was unable to bend his fingers. Sleep then sud-
denly deserted him, and he declares that for a fortnight prior to his admission
into the Infirmary he did not sleep a single hour, owing to the intensity of the
pain in the tumour and along the arm.

Symptoms on Admission. — A tumour equal in size to the largest goose egg
occupies nearly the entire of the supra-clavicular region, extending from the
clavicular attachment of the sterno-cleido-mastoid to the acromial end of clavicle,
which has a strong pulsatory movement that is visible from the most remote
part of the ward, and is accompanied with a loud bruit de soufflet; it is soft and
compressible ; and is red and somewhat inflamed on the surface, from which
circumstances Doctor Greer, under whose notice the patient first came, greatly
feared the aneurism would have burst. There is no appreciable dulness on
percussion under right clavicle, but the respiratory murmur is not as distinct

1857.]

Surgery.

245

as on the opposite side ; however, this may arise from its being somewhat
masked by the loud bruit on that side ; the superficial veins of head and neck
are considerably enlarged, but he does not suffer either from cough, dyspnoea
or dysphagia; tongue tolerably clean, pulse at wrist 80, and regular; appetite
not good. His chief source of complaint is a severe and constant pain extend-
ing from the tumour down the right arm as far as the tips of the fingers, which
he says is most acute about the middle of the humerus, and he is constantly
compressing this part with the other hand, conceiving that it gives him some
relief. At first he got sedatives, had cold applied to the aneurism, and
each night had a full anodyne, which treatment somewhat moderated the vio-
lence of the pulsation, and made him feel more comfortable, and after a few
nights, when the anodyne had been considerably increased, he got some tran-
quil rest.

In December he was bled twice from the arm, and ice was kept constantly
applied over the tumour for three weeks, without any manifest improvement,
except that the redness and inflammatory appearance of the integument cover-
ing the aneurism have completely disappeared ; in other respects, the symp-
toms remain unaltered. Having seen the report of Mr. Fergusson's very
interesting case, I resolved to follow his suggestion in this apparently hopeless
one, and I must confess I did so without any very sanguine expectation of
success. Accordingly, on the 1st of January, 1856, by making gentle but
steady pressure with my thumbs alternately over the aneurismal sac, I suc-
ceeded in displacing some of the coagula, and directing them towards the
distal end of the artery. No other local treatment was adopted, but he was
ordered the persesquinitrate of iron internally. For the first two days no
change was perceptible in either the tumour or the arm ; but at the third day
the pulse at the wrist was manifestly weaker, and the arm somewhat colder
than the opposite one. These symptoms gradually increased up to the tenth
day after the manipulation of the sac, when no pulsation could be felt in either
radial, brachial, or axillary arteries. The tumour itself had now become more
solid, and the bruit and pulsation were both diminished ; the violent pain in
the tumour and along the arm has also decreased, but now he complains of a
sensation of coldness over the right shoulder and scapula, and of a severe pain
extending along the side of the neck and back of the head, which increased
in severity for a month, and the arm became greatly wasted, and partially
paralyzed, retaining very little sensation and scarcely any power of motion.

March. All pulsation in the aneurism having now ceased to be visible, pres-
sure was applied over it.

November. Both bruit and pulsation have completely disappeared ; the aneu-
rism is not more than one-third its original size, and is quite solid; the anterior
edge of clavicle feels thin and sharp, from the absorption of its upper surface,
caused by the pressure of the sac, and the pain alongside of head and neck,
heretofore so much complained of, has completely subsided. The arm has
regained its natural temperature, and, although still considerably attenuated,
he can use it tolerably well, sensation having also returned to it. A very slight
pulsatory wave can now be felt in the radial artery, but not in either brachial
or axillary. Two superficial arterial branches, of considerable magnitude, can
also be traced, running in a transverse direction across the remains of the
aneurism, one immediately above the clavicle, the other somewhat higher up.

March, 1857. — Having again admitted the patient into the Infirmary within
the last few days, for the purpose of examining his condition, the absorption of
the tumour is steadily progressing, being now not larger than a walnut. Pulse
at the wrist somewhat stronger than at last report, but still not to be felt in
either brachial or axillary. Sensation and motion are completely restored to
the arm. He is free from all pain, and says he feels perfectly well, and intends
resuming his former occupation. I may mention that most of my medical
brethren in this locality having taken a deep interest in this case, and visited
him from time to time while under treatment, have also seen him since his last
visit to the Infirmary, and agree with me in considering the cure to be most
satisfactory and complete.

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35. Ligature of Arteries in Suppurating Wounds. — In one of his recent clinical
lectures, M. Nelaton made the following observations, the occasion being a
secondary hemorrhage in the palm of the hand. Nothing is more difficult, he
observed, than to arrest a hemorrhage of the hand, especially when this is con-
secutive— that is, when the wound is covered by pyogenic granulations. If not
previously instructed as to the proper management of these secondary hemor-
rhages, you will be extremely embarrassed. The blood flows, you employ com-
pression, and it ceases ; but the hemorrhage will not be long before it returns,
and will then be uninfluenced by compression. If compression be made above
the wound, oedema takes place in all the subjacent parts, and the hemorrhage
soon returns. The radial, or the ulnar, or the brachial may be tied, and yet
the bleeding does not stop. Meeting such a case, M. Nelaton formerly was
quite at a loss to know what to do, impressed as he was with Dupuytren's dic-
tum, that arteries in a suppurating wound will not bear the ligature, the pre-
mature fall of this infallibly giving rise to a return of the hemorrhage. Never-
theless, he ventured to tie the two ends of the bleeding vessel of the palmar
arch ; and although the ligature fell sooner than usual, no hemorrhage fol-
lowed. He has frequently since then tied vessels under analogous circum-
stances, and has never seen hemorrhage as a result of the fall of the ligature.
Although, therefore, this fall takes place earlier (usually about the third or
fourth day) than is the case with a ligature applied to a healthy artery, it is
not premature, for bleeding does not follow. Examining the matter experi-
mentally upon the dead body, M. Nelaton has found that ligatures applied to
arteries in a state of suppuration (as in patients who have died after amputa-
tion) produce identically the same effects upon the coats of these vessels as
upon arteries remote from the seat of inflammation ; the same division of the
inner coats and preservation of the outer taking place in the two cases. He
feels, therefore, perfect confidence in the soundness of the practice; supported
as it is by numerous cases that have occurred to him, both in private and
hospital practice. — B. and F. Med.-Chirurg. Rev., April, 1857, from Gaz. des
Hdpitaux, 1857. No. 1.

36. Forcible Extension and Rupture of the Uniting Medium of Partially An-
chylosed Surfaces. — Mr. Brodhurst read before the Royal Medical and Chi-
rurgical Society (March 24, 1857) an interesting paper on this subject. He
commenced by stating that excision of the articular surfaces of bones is at the
present time an operation of frequent occurrence, and that it is undertaken not
as a substitute merely for amputation, but that this operation is performed in
cases where amputation would not be thought of, and where forcible rupture
of partially anchylosed surfaces would be advantageously had recourse to. He
related three cases of partial anchylosis of the knee, in which the adhesions
were ruptured, and motion was restored. He also cited three similar cases in
which the articular extremities of the bones were excised, and related four
cases of partial anchylosis of the hip, and one case of partial anchylosis of the
elbow; in all of which rupture of the uniting membrane was successfully per-
formed. The author then gave a brief historical sketch of the operation, to
show the means which have been hitherto adopted in the treatment of these
cases, and to contrast them with those which he has practised, and which he
recommends ; and concluded with some details as to the after-treatment adopted
by himself. The cases related were —

1. A youth, aged 14, with partial anchylosis of the knee at a right angle,
together with sub-luxation of the tibia backwards, of nine years' duration.

2. A female, aged 42, with angular false anchylosis of the knee, together
with sub-luxation of the tibia backwards, of ten years' duration.

3. A female, aged 17, with angular false anchylosis of the knee, which had
existed one year.

4. A female, aged 8, with angular false anchylosis of the hip-joint, of three
years' duration.

5. A female, aged 13, with false anchylosis of the hip, of four months'
duration.

1857.]

Surgery.

247

6. An artillery officer, aged 25, with false anchylosis of the hip-joint, of
fourteen months' duration.

7. A gentleman, aged 21, with partial anchylosis of the hip-joint, of twelve
year?' duration.

8. A boy, aged 8, with angular false anchylosis of the right elbow, of five
years' duration.

The author stated that in no instance did inflammation occur ; and also that
in all these cases motion was obtained. In some, complete power of motion
in from six weeks to three months ; in others, less extended motion. He con-
cluded that fibrous adhesions may safely be ruptured when they have formed
between articular surfaces. And he recommended that when muscular retrac-
tion exists, and there is much rigidity present, the tendons should first be
divided, and subsequently the adhesions should be ruptured, when the punc-
tures have healed.

Mr. Ure said, that Professor Langenbeck laid great stress upon the reduction
of the tonic contraction of the muscles by chloroform, rarely resorting to sub-
cutaneous section, except in the cases to which Mr. Brodhurst has referred
where fasciee or cicatrices interfered. In his memoir, Langenbeck mentioned
six cases of anchylosis overcome by his method, five of the knee-joint, and one
of the hip-joint — the ages varying from 4 or 5 to 35 years. In some cases, the
patients walked about in a fortnight or three weeks after the rupture by alter-
nate flexion and -extension of the diseased articulations. Very little after-
treatment was found necessary, simply a small dose of morphia, and occasion-
ally iced applications ; in one or two cases leeches were applied, and venesection
was resorted to in one instance. He (Mr. Ure) had adopted Langenbeck's
plan in the case of a little girl in St. Mary's Hospital, who suffered from con-
traction of the knee-joint, and a great improvement was the result.

Mr. Henrf Lee said the author had described the advantage of subcutaneous
section of the tendons and fascias in cases of partial anchylosis. In those
cases there must be some effusion of matter, more or less solid, into the joint;
and where that was the case, it must be apparent, if the ligaments were left
entire, that any forcible extension of the joint must not only lacerate, but
occasionally bruise and crush the ligaments. The surfaces of the articular
cartilage must be altered in their outline ; so that it might be impossible for a
semi-anchylosed joint, even if the adhesions were free, to be moved. In cases
where inflammation affected the ligaments without any alteration of the articu-
lar cartilages, it was often impossible fully to extend or flex the joint, on
account of the alteration that had taken place in the ligaments. He wished to
ask Mr. Brodhurst whether he had tried the plan of dividing the ligaments. It
appeared to him (Mr. Lee) that if the ligaments could be subcutaneously
divided, the joint might be extended with much less force and injury to the
parts, and very much less chance of inflammation. It might be said that there
would be a chance of opening the joint; but if that were so, the opening of a
joint under such altered circumstances would be nothing in comparison to the
opening of a sound joint.

Mr. Charles Hawkins asked the author whether the cases he had enume-
rated included all that he had met with in his practice, or whether he had had
cases which had not terminated so successfully. He (Mr. Hawkins) should be
very much disinclined to interfere with a well anchylosed joint, especially the
hip-joint, where extensive disease had existed. The cases related by the author
certainly appeared to be extraordinarily successful, but he should be glad to
knowr whether there was any return of the disease, or whether in any cases
matters had been left worse than before. He had seen great improvement in
the shape of extremely distorted joints by properly applied instruments, with-
out rupturing or dividing the tendons.

Dr. Wood bore testimony, from personal observation, to the very successful
termination of the case of the officer of artillery mentioned by the author.

Mr. Spencer Wells said he had seen Langenbeck' s practice in Berlin in
1853, and could testify to the groundlessness of the fears expressed by Mr.
Hawkins as to the after results of the system. He saw six cases in which the
operation was performed — two upon the elbow-joint after a fracture of the in-

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Progress of the Medical Sciences.

[July

ternal condyle of the humerus, one or two upon the hip-joint, two or three
upon the knee-joint, and in no case did a bad symptom present itself. The
patients were fully under the influence of chloroform, and one of them was
operated on a second time. The success of the operation had encouraged him
to perform it himself in a case in which the internal condyle of the humerus
had been fractured; the limb had been firmly flexed upon the arm, but it
yielded to extension, and motion was re-established without any ill effect.

Mr. Brodhurst said that on a recent occasion at Vienna, a paper was read
by Pellassiano on partially anchylosed joints. A discussion followed, which
was stopped by the President (Dumreicher) observing, that the question had
been already settled ; the division of tendons being considered in Germany
unnecessary, forcible extension without such division being all that was re-
quired. It was in consequence of that statement that he (Mr. Brodhurst) had
brought the subject before the Society. It appeared to him that the President
had prejudged the question, and that (judging from the cases of Langenbeck
and Louvrier, the tendons ought to be divided where great rigidity existed,
though in other cases, such as those to which he had referred, the division was
not necessary. He had seen no evil results from extensions, except in one case
in which a troublesome inflammation was set up, but it was overcome, and
motion was subsequently gained. It was true, as Mr. Lee had observed, that
the structure of the joint was changed in such cases ; but he had not found it
necessary to divide the ligaments. Indeed he should hesitate to extend the
limb immediately after having used the knife. That, he believed, had been
the great fault committed in the operation, leading to inflammation, abscess,
and other untoward symptoms. He had not more than fourteen cases, all of
which had turned out extremely well. It was difficult to lay down the patho-
logical conditions in which this operation should be performed, since they dif-
fered so extremely. In some cases the adhesions were within the joint, and in .
others they were external. The cases in which the joint was not immediately
implicated, were of course the most favourable for the operation. In one of his
cases resection had been proposed, and it was only because such a violent ope-
ration had been suggested that the patient had been sent to him (Mr. Brod-
hurst).— Med. Times and Gaz., April 4, 1857.

37. Excision of the Head of the Femur and Floor of the Acetabulum for Caries
combined with Febrile Abscess. — Mr. Henry Hancock records [Lancet, April 25,
1857) the following remarkable case: —

" Timothy D , aged 14, admitted under my care, into Charing-cross Hos-
pital, in July, 1856, with disease of the hip-joint. Five years before, observing
a swelling in the groin, he attended at the Middlesex Hospital, but got worse,
and was made an in-patient. He remained there five months. Two years
afterwards, abscesses formed around the joint; and, eighteen months ago, he
first came under my care at Charing-cross Hospital, where he remained three
months, when he left apparently cured. He continued able to walk for ten
months, when he was attacked with severe pain in the knee, which increased
so much, that upon his application I again admitted him into the Hospital.
Shortly afterwards, abscesses formed around the hip-joint, opening behind the
trochanter, and also low down on the back of the thigh ; and, subsequently,
an abscess burst in the groin ; and a probe introduced into this opening passed
readily into the pelvis. He, in the course of time, became so emaciated and
worn out with the profuse discharge, night-sweats, loss of appetite, &c, that it
was evident he could not long survive if something were not done for him.
Great prostration and cough supervened, and his sputa became streaked with
blood. I therefore requested Dr. Willshire to examine his lungs. He did so,
and pronounced them free from any cause contraindicating an operation.
Having so far as possible ascertained that the disease was confined to the hip-
joint and pelvis, I examined the inside of the latter with a probe through the
opening in the groin, and then discovered perforation of the acetabulum.
Under these circumstances, I concluded that the pelvic abscess, and the boy's
condition generally, were due to hip disease, and that by removing the head
of the femur, and the floor of the acetabulum, I might not only get rid of the

1857.]

Surgery.

249

diseased bone, but also by affording a free and depending opening for the dis-
charge of the matter, the pelvic abscess might be approximated to the condition
of an ordinary abscess, and thus the patient be saved ; and I accordingly pro-
posed to my colleagues to remove the head of the femur and floor of the aceta-
bulum, and so much around it as the extent of the disease required, the patient
having agreed to undergo whatever I might advise. On the 6th of December,
1856, the patient having been submitted to the influence of chloroform, and
placed upon his left side on the table, I, assisted by Mr. Canton, Mr. Hird, and
Mr. Barwell, commenced the operation by making a crucial incision over the
great trochanter of the femur, extending about three inches beyond in all direc-
tions. The flaps having been reflected, a circular incision was carried round
the head of the bone, which remained in its cavity, cutting through the glutsei,
the muscles inserted into the digital fossa, the pectineus, &c, and opening the
capsular ligament. Upon examination by the finger, the neck of the femur
was discovered to be so much involved in the disease that I decided upon cut-
ting through the bone immediately below the great trochanter ; after which, the
head of the bone was removed without difficulty. When this was done, the
acetabulum was found to communicate by two openings at its deepest part with
the pelvic abscess. I endeavoured to excise the floor of the acetabulum with
the bone-nippers, but could not, and therefore with a metacarpal saw I cut
round the acetabulum, removing the whole of the diseased bone, exposing the
thickened pelvic fascia, and leaving a large opening for the escape of the matter
from the pelvic abscess. It has been stated in another journal that I gouged
away the several- portions of the acetabulum. This is an error; I did not use
that instrument at all. The flaps were then brought together, and united by
sutures, except opposite and below the opening in the acetabulum, where they
were kept separated by lint. A splint, extending from the armpit to the foot,
was next applied, as the leg could now be straightened without difficulty, and
the patient returned to his bed. Very little blood was lost during the operation,
and no vessels required tying.

" The operation was followed by almost instant relief of his constitutional
symptoms. He was a little sick for the first forty-eight hours from the chloro-
form, but otherwise his course has been one of uninterrupted improvement.
His countenance soon became cheerful and free from anxiety ; his night-sweats
ceased in two days from the operation. On the third day, the wound in the
groin was entirely healed. The discharge from the wound made at the opera-
tion, which for the first few days was very abundant, gradually became thicker
and diminished in quantity until the present time, when it does not amount to
a teaspoonful during the twenty-four hours. He was able to sit up in bed for
the first time for nearly a year with his knees straight fourteen days after the
operation. In there weeks, he dressed himself, and sat in a chair by the fire.
In five weeks, he was able to walk with a crutch and a stick ; at the end of
eight weeks, however, he imprudently dispensed with both crutch and stick ;
inflammation ensued, followed by abscess external to the pelvis. This, how-
ever, has subsided, and he is now progressing steadily, gaining flesh and
strength, at the present time being able to walk in the park daily."

38. Treatment of certain Diseases of the Knee-joint by the Operation of Re-
section.— Mr. Price read before the Medical Society of London (March 14) an
interesting paper on this subject. He stated that nearly seven years had
elapsed since the revival of the operation by Mr. Fergusson. During this in-
terval the subject had excited the greatest attention, and many opinions had
been offered regarding its value and its right to be admitted as a recognized
operation in surgery. It could not be denied that the general feeling had been
obnoxious to its admissibility, and although it had been approved by many
excellent authorities, it had nevertheless been condemned, in a manner, per-
haps, unprecedented in the history of surgery. Opinions had been expressed
by many quite incapable of forming a correct judgment, and many whose high
attainments had eminently fitted them to be impartial judges of the merits and
faults of the operation, had, with a spirit unbecoming their character and dig-
nity as surgeons, placed themselves in direct opposition to every improvement

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Progress of the Medical Sciences.

[July

and suggestion connected with its advancement. It was admitted that many
errors had been committed, and that the intention of the operation had on more
than one occasion been overstrained, yet in the limited number of cases re-
corded, a success had been achieved which forcibly disposed of all theoretical
objections which had been offered, and fully warranted a more extended trial.
The author then eulogized Mr. Butcher's labours in connection with the sub-
ject of resection, and thought that the ancient motto, " Nemo ex libris evasit
artifex" — no man becomes a workman from books — was, perhaps, appropriate
as applied to himself on the present occasion, as the remarks he had the honour
of making to the Society were derived entirely from experience. Twenty cases
of the operation had fallen under his immediate notice — one-fifth of the entire
number which had been recorded since it was adopted by Park in 1781. Three
of these operations had been performed by himself ; in the remainder he had
been either an assistant or an interested spectator, and had enjoyed the privi-
lege and opportunities of watching the subsequent treatment, which had
enabled him to accumulate a mass of information and facts which had strongly
impressed him with the value of the operation on all suitable occasions. The
author then lamented the frequency of amputations when resection was not
only admissible, but a right and superior operation. The principal affections
of the knee-joint, which are more or less amenable to the operation of resection,
were classed under the following heads: —

1. Inflammation of the synovial membrane, acute and chronic.

2. That class of affections which Sir B. Brodie includes under the title of
"where the synovial membrane has undergone a morbid alteration of
structure."

3. Where ulceration of the articular cartilages had arisen as a primary
affection.

4. Scrofulous disease of the cancellated ends of the bones entering into the
formation of the joint.

Discarding all very acute cases of these affections, with their various compli-
cations, few surgeons probably could be found who would venture, on practical
grounds, to dispute that these diseases are frequently amenable to the great
conservative operation of resection. With regard to cases of acute inflamma-
tion of the synovial membrane demanding prompt removal of the source of
irritation, the author believed resection was, as a general rule, unwise. The
acute nature of the symptoms, the sympathy of neighbouring structures, and
of the entire system, with the unfavourable condition in general of the patient,
were sufficient reasons for preferring amputation. The danger following re-
section in such cases was the liability of the ends of the bones to take on an
unhealthy action. Experience had incontestably proved that such an untoward
occurrence was very apt to ensue. Pyaemia had on several occasions carried
patients rapidly away, and acute necrosis had also quickly terminated in death,
or demanded immediate amputation, provided a limitation of the inflammation,
and subsequent exfoliation of the part, could not be expected. In the more
chronic forms of synovial disease, the operation of resection was of far higher
value. In cases of this class, not by any means uncommonly met with amongst
the poorer classes, the proceeding had been frequently resorted to with much
benefit. During the last six years, the statement of an eminent author (Brodie
" On the Diseases of the Joints") : " Fortunately in this extremity an accurate
diagnosis was of no great importance, as it can lead to no essential difference
in the surgical treatment of the case," had been disproved, for amputation had
been superseded by the more humane operation of resection. The author,
however, was by no means inclined to admit that such cases were the most
favourable for the operation, but he did admit that they could be, with pro-
priety and judgment, treated in this way much to the advantage of the patient
and to the credit of surgery. If there be in reality any value in the operation,
the author believed it to be exemplified in its adaptation to the treatment of
various cases which were included under the title of " where the synovial mem-
brane has undergone a morbid change of structure." A moment's considera-
tion would convince the most obnoxious dissenters to the operation of its great
advantage. There was seldom seen any extensive and acute inflammation

1857.]

Surgery.

251

breaking down fibrous, cartilaginous, and bony structures; very often no ema-
ciation, and long suffering inducing hectic and irritative fever. The patients
were for the most part otherwise healthy, and, perchance, submitted to an
operation more for the sake of convenience and comfort than an escape from
suffering and death. These, and other features, would pre-eminently recom-
mend resection to the more general consideration of the profession for affec-
tions of this class. In cases of acute ulceration of cartilages, occurring as a
primary affection, the author was led to take an unfavourable view of resection,
provided the symptoms were extreme, and especially if evidence existed of the
participation of the bones in the disturbance. In cases of a more chronic or
subacute character, the operation must be looked upon as highly advantageous,
as experience and facts have attested the good effects of its adoption on many
occasions. It was, however, to the employment of resection of scrofulous dis-
ease of the knee-joint, commencing in the cancellated tissue of the bones, tibia,
and femur, that the author particularly wished to direct attention. Great stress
was placed upon a right appreciation of an operation more or less applicable
on many occasions. The pathological changes that take place in the meshes
of the ends of the bones, and their cartilaginous coverings, were well illus-
trated by some beautiful drawings, from the pencil of Dr. Westmacott, from
cases which had been treated by Mr. Fergusson, and by the author. From the
history of cases of this class in various stages of disease that had been treated
by the author and other surgeons, it appeared that resection was an operation
highly useful in the treatment of joints extensively destroyed by strumous dis-
ease, and that extensive destruction of the cancellated ends of the bones is of
little consequence, provided all the disease be removed from contact with the
healthy parts. The extent to which parts so diseased might be removed, was
illustrated by a remarkable case, under the care of Mr. Jones, of Jersey, in
which the upper half of the tibia, as well as the entire articulation, was re-
move I with success. These being the principal classes of disease for which
the operation had been undertaken, the author next proceeded to inquire how
it was that, considering the apparent advantages of resection, so much dispute
regarding its employment had arisen ? This was attributed, in a great mea-
sure, to the general ignorance, but professed knowledge, that existed regarding
it, and also to the lethargy and unwillingness that prevailed amongst many
surgeons to adopt a new proceeding, or which, having been adopted on one
occasion, and signally failing, through want of due skill and judgment, had
not been repeated, the ill success being unfairly attributed to the operation.
Many teachers had attempted to instruct their pupils on a subject concerning
which they were themselves not particularly enlightened, and in so doing had
laid themselves open to the criticism of the better informed. The operation
had lately been denounced by Mr. Syme as "bloody and formidable;"1 and
yet, at the time, that gentleman was somewhat acquainted with the operation,
he distinctly taught and wrote that " there is not much bleeding, but one or
two of the articular branches may require to be tied."2 If, then, the former
expression had reference solely to the subject of hemorrhage, occurring at the
performance of the operation, Mr. Syme, without any further experience,
would appear to have contradicted himself. A comparison between the results
of resection and modern amputation of the thigh was shown to be unfair. If
comparisons were to be drawn between resection and another operation or in-
jury, the author would feel more inclined to liken it to a severe compound
fracture. "With regard to the performance of the operation, the advantage
gained by not removing the entire epiphyses was shown to be advantageous in
two ways. Osseous union would be more likely to take place, and the new
product would be in many ways better adapted as a bond of union; and
secondly, should unhealthy inflammation of the ends of the bones succeed in
destroying the bony structure, provided the epiphyses have not been removed,
the mischief may be entirely confined to this portion of the bone. Such an un-
fortunate occurrence was apt to arise from two causes : damage inflicted on the

1 Vide Introductory Lecture, by Mr. Syme, in The Lancet, Nov. 15, 1856.

2 Syme on Excision of Diseased Joints, 1831.

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ends of the bones at the time of the operation, or during the after-management.
Both these mishaps the author had seen, on more than one occasion, to prove fatal.
He must again call attention to the great importance of correct after-treatment,
and strongly recommended the splint described on a former occasion by him-
self. Division of the hamstring tendons had been devised, " as all tendency to
after-mismanagement is checked. Such a statement had been made partly on
supposition, for hideous deformity had more than once arisen from so doing;
it was therefore necessary duly to consider the propriety of this proceeding.

Many excellent water-colour drawings and casts of limbs after the operation
were exhibited, showing the condition of various specimens of diseased joints
which had been treated by resection. — Lancet, March 21, 1857.

39. Bony Union after Fracture of the Cervix Femoris within the Capsule. —
T. Bryant, Esq., exhibited to the Pathological Society of London (Feb. 3, 1857)
a specimen of this, which is worthy of note in connection with the valuable
paper by Prof. Mussey, inserted in our preceding number.

" Mary H., aged 60, a lunatic inmate of the asylum at Guy's Hospital five
years ago, when walking in the garden, fell and fractured her right thigh-bone.
All the symptoms of fracture of the neck of the femur within the capsule were
present, clearly indicating the character of the injury. A long splint was ap-
plied; but much difficulty was experienced in preserving the leg in the right
position, from the restlessness of the patient. After some weeks' confinement
she was allowed to sit up, but her health soon began to fail, and she never
walked again, and on June 30 she died. The specimens shown consisted of
the upper parts of both thigh-bones. On the injured side union was complete,
and had partly been effected by bone, partly by cartilage, and in part by fibrous
tissue.* The whole of the neck had been absorbed, and the articular head was
united directly to the base of the great trochanter. The union was very firm,
and the head of the bone was much indurated.'' — British Medical Journal,
March 14.

40. Ununited Fracture Remedied by Operation. By James SrME,Esq. — There
are few results of surgical practice so distressing and embarrassing as imper-
fection in the osseous union of a broken bone, since, in general, so long as this
condition continues to exist, the limb concerned is rendered nearly if not
entirely useless, while the means of remedy hitherto employed have proved
uncertain of good, and sometimes even productive of bad effects. When there
is merely a slight degree of mobility at the seat of injury, so that, although
quite sufficient to prevent any useful exercise of the limb, it may require some
care for its detection, there will be a favourable prospect of success, even after
the expiration of several months, through the employment of means for the com-
plete prevention of motion ; and I have put upon record cases in which even
the thigh-bone was rendered perfectly rigid by this simple expedient, in cir-
cumstances of apparently a very hopeless character, from the long duration of
flexibility. But when the extremities of the bone remain quite separate, or
even overlap each other, and are surrounded by a sort of fibrous capsule with
cellular interstices, so that they admit of hardly less free motion than if there
really were a joint between them, it is evident that merely preventing motion
could not possibly prove sufficient for the production of an osseous union. It
has been supposed that the difficulty thus presented might be overcome by
rubbing the ends of the bones together ; by stirring up the texture connecting
them through the agency of needles or tenotomy knives ; by passing setons
through the flexible medium of union ; and by inserting pegs of ivory into the
respective osseous surfaces. But, so far as I am able to form an opinion on
the subject, all of these means are absolutely useless, and owe any share of
credit that they may have acquired to the prevention of mobility which is con-
joined with their employment. In short, I believe that the procedures in ques-
tion cannot accomplish recovery in any case not remedial by the enforcement
of rest, and that they, consequently, must always be useless, if not injurious.
There is still another mode of treatment, which consists in cutting off the ends
of the bone, so as to obtain two fresh osseous surfaces, and place the limb in a

1857.]

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253

condition similar to that of a compound fracture recently inflicted ; and this, I
feel persuaded, affords the only reasonable ground for expecting success in
cases not amenable to the influence of immobility. It is true that the experi-
ence of this method has not hitherto been at all satisfactory, through want of
due attention to some circumstances in the mode of procedure, which must in
a great measure determine the result. Of these may be specially mentioned
an imperfect removal of the ends of the bone, and a want of complete immo-
bility after the operation. The following case will, I hope, tend to illustrate
the importance of attending to these points.

J. H., aet. 34, a private of the foot, while discharging some duty in

the Redan, on the 8th of December, 1855, after the occupation of Sebastopol,
was blown up by a Russian mine, which had escaped detection, and, in addi-
tion to some slighter injuries, sustained a fracture of the left arm between two
and three inches above the elbow. He walked up to his regimental hospital,
where splints were applied, and retained for a month, when, there being no
signs of union, the ends of the bone were rubbed together, and supported by a
starched bandage. He left the Crimea on the 3d of February, and was sent to
the hospital at Renkeioi, where a seton was passed through the seat of fracture,
and retained for five weeks without any benefit. On the 20th of May he pro-
ceeded homewards, and, after a long voyage of nearly two months, arrived at
Portsmouth, whence he was transferred to Chatham on the 17th of July. No
attempt to restore rigidity was made there, and at the end of two months he
was dismissed the service, with a pension of one shilling per day, in considera-
tion of his disability, which was regarded as equal to the loss of a limb.

In the hope that relief might still be afforded, he applied to me on the 22d
of January last, nearly fourteen months from the date of the injury ; and find-
ing that the arm was entirely useless through the extreme mobility of the ends
of the bone, which overlapped each other to the extent of more than an inch, I
resolved to adopt the only procedure that, in my opinion, afforded any reason-
able prospect of remedy under such circumstances, which was to remove the
ends of the bone, and afterwards maintain the most perfect rest. In prevent-
ing the motion of a joint, it is a most important principle, never to be forgotten,
that as most of the muscles pass over two articulations, it is impossible to keep
any one perfectly quiet without placing the whole limb under restraint. Pro-
ceeding under tlr's impression, my first step was to have the arm put in an
easy position, with the elbow bent at a right angle, and then covered from be-
yond the shoulder to the tips of the fingers with pasteboard and starched
bandages, so as to form a case, which, when it became dry, effectually pre-
vented the slightest movement in any of the joints. This case was next cut up
on one side from end to end, so as to allow the arm to be taken out of it, and
undergo the requisite operation, which was performed under chloroform. An
incision having been made along the outer edge of the triceps, I exposed the
upper end of the bone, and sawed off a portion of it sufficient for obtaining a
complete osseous surface. The lower end, lying anterior to the shaft in a sort
of capsule, could not be subjected to the saw, but was removed, to the extent of
more than an inch, by cutting pliers. The arm was then supported by a cou-
ple of splints, and the patient lay quietly in bed for a fortnight, when the limb
was placed in its pasteboard case, in which an aperture had been made over
the wound, then nearly healed, and discharging a very little matter that soon
ceased entirely. The patient, feeling that the slightest motion was impossible,
even if he had wished it, was relieved from any further restraint, and no longer
remained in bed. At the end of a month, or altogether six weeks from the
date of the operation, which was performed on the 30th of January, the limb
was examined, and found to be quite straight, with a firm osseous union ; so
that the patient was able to leave the hospital, not only with his comfortable
pension, but also with a perfectly useful arm. — Edinburgh Med. Joum., May,
1857.

41. Case of Myopathic Luxation. By Dr. Friedberg. — 0. H., when fifteen
months old, fell with his left hand stretched out, and some hours' after com-
plained of pain in the arm. Two days later, swelling was observed at the
No. LXVIL— July 1857. 17

254

Progress of the Medical Sciences.

[July

wrist, as well as at the shoulder and left cervical region; that of the latter
parts not disappearing for five or six weeks. It was found then, that although
the child could use its arm, it forbore as far as possible, occasionally complain-
ing of pain in it. At a still later period, frequent fugitive convulsive move-
ments of the limb appeared, as well as progressive emaciation.

Various means having been uselessly tried, the boy, two years after the
accident, was brought to the author's clinic. The left arm was then found to
be an inch longer than the right. The upper arm had lost a sixth of its cir-
cumference, but the other parts of the extremity were less emaciated. The
emaciation affected the pectoralis major, the latissimus dorsi, the anterior supe-
rior portion of the trapezius, and all the muscles proceeding from the shoulder-
blade to the arm. The middle portion of the deltoid had almost disappeared,
as had the supra- spinatus at its external two-thirds. The scapula and humerus
were normally developed. The acetabulum was empty, but its capsule was
not thickened. The head of the humerus, which had sunk downwards an inch,
could be easily restored to its place, from which, however, it immediately fell
down again. Slight fibrillary contractions were observed in the muscles about
the shoulder, the force of which was somewhat increased on the application of
cold. The child could not execute any movement of the upper arm ; while
electricity only excited feeble contractions in the pectoralis, latissimus, and a
portion of the deltoid, the middle of this last and all the muscles of the humerus
being insensible to its action.

The child's health and development were good, and the author saw him yet
a year later. The affection had continued to make progress, so that the left
arm was a fourth less in circumference than the right, and hung motionless by
the side ; while the elasticity of the muscles of the forearm had diminished,
as had the power of using the hand. The muscles attached to the humerus
seemed like mere thin relaxed cords, and its development, as well as that of the
scapula, had been remarkably retarded. The disappearance of the deltoid was
almost complete, and the glenoid cavity seemed to have become more super-
ficial. The lower half of the trapezius and the rhoniboideus had also remarkably
diminished.

Thus it appears that all the symptoms which have been assigned to the so-
called progressive muscular atrophy may arise from traumatic inflammation of
muscles. At the time of the accident in this case, the muscles surrounding
the shoulder-joint underwent violent traction through the sudden pushing up-
wards of the head of the humerus. This was followed by pain and increased
sensibility, and afterwards by the relaxed state of the arm. The inflammation
not being dissipated, led to degenerative atrophy, which extended from the
muscles originally involved to the others in their vicinity.

In explanation of the direction taken by the luxated humerus, Dr. Freidberg
observes, that the disturbance of the nutrition of muscles, which leading to
their relaxation, may permit dislocation, may occur in various ways, whether
from the operation of violence, the propagation of inflammation from a joint,
the poisoning the blood as by lead, or scarlatina contagion, through a con-
tinued interruption of innervation, or a diminution of the supply of arterial
blood, &c. This deprivation of their elasticity renders them unable to oppose
the action of their antagonists. This myopathic luxation may occur in different
joints under more or less complicated conditions ; and it is met with in its
simplest form in the shoulder. Here it might indeed a priori be especially ex-
pected to occur, owing to the extensibility of the capsule and ligaments, ren-
dering the retention of the head of the bone within the cavity exclusively a
muscular action. And thus it is, while in the shoulder-joint a complete luxa-
tion may be the immediate effect of a myopathic paralysis, in other joints such
luxation is at first only incomplete, its completion depending upon other
secondary circumstances. For the production of a dislocation perpendicularly
downwards, as observed in the present case, it is essential that the supra-
spinatus muscle be either torn, or have lost its elasticity in consequence of the
disturbance that has been produced in its nutrition. — B. and F. Med.-Ohirurg.
Rev., April, 1857, from Oesterreichische Zeitschrift, 1857, No. 1.

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Surgery.

255

42. Inflammation and Rupture of the Rectus Abdominis. — In our number for
January last we published an interesting case of rupture of the right rectus
abdominis muscle, by Dr. Richardson, of Louisville. The following abstract
of a paper recently contributed by Yirchow (Wurzburg Verliandlungen) is
interesting in relation to that case.

" During the last few years, several cases of inflammation and rupture of this
muscle have come under his notice, which have proved interesting from the
analogy they bear to examples of myocarditis and rupture of the heart. In
most of the cases, the rupture has occurred about midway between the umbili-
cus and the pubes, usually being confined to one side. In some cases in which
he has found parenchymatous changes without rupture, these have always been
found towards the lower part of the muscle.

"Isolated rupture of muscles from external violence are of very rare occur-
rence ; and where great traction has been exerted, it is rather the tendon than
the muscle that gives way. So, too, the ruptures which sometimes take place
from excessive action, as in tetanus, must be very rare, and of a microscopic
character. Those resulting from excessive rigor mortis, described by Roki-
tansky, M. Yirchow has never seen. The comparatively frequent parenchy-
matous or spontaneous rupture presupposes organic changes of the muscle,
inducing a pathological fragility. It is characterized by the slight amount of
force necessary for its production, and the existence of changes in the imme-
diate vicinity "of the rupture, which are not infrequently, to greater or less
extent, in other parts of the muscle. These changes Yirchow has exactly de-
scribed in his account of muscular inflammation, in the 'Archiv' (band iv. p.
266). They may consist in either a true fatty metamorphosis of the interior
of the primary bundles, or of peculiar softenings which at last lead to a granular
degeneration of the muscular substance. This last form it is that often excites
inflammatory appearances, which are especially seen during metastatic pro-
cesses, but which may be produced in the same way as in the heart when its
supplying arteries are obstructed. The first form takes place more slowly, as
in aged persons, in paralytic parts, and after protracted muscular inactivity.

" So far as Yirchow has observed, rupture of the rectus has always been pre-
ceded by this organic metamorphosis of its substance ; and in quite recent
cases, the same changes have been found at the circumference of the ruptured
parts which have been found in diseased but unruptured muscle. After de-
scribing the microscopic appearances at the various stages of the affection, he
goes on to say that he has always found rupture commencing at the posterior
or peritoneal surface of the diseased muscle. The ruptured part becomes at
once filled with blood, which coagulates and may be infiltrated, or projecting
and visible through the peritoneum. Of the 7 cases Professor Yirchow has met
with in three years, 4 occurred in women aged nineteen, thirty-five, fifty-nine,
and sixty-five years; and 3 in lads of fifteen, twenty-two, and twenty-three
years. Four of the cases were examples of typhus, most having entered the
ulcerative stage ; in 2 others there was marked tuberculosis, and in another
scorbutus. In most of the cases the proximate cause of the rupture was violent
coughing. Yirchow believes that some of the cases described by authors as
" neuralgia epigastrica," "peritonitis musculosus," " rheumatismus muscul.
abdoni.," may be examples of such rupture, going on in certain instances to
suppuration."

43. New Method of Operating for Impermeable Urethra. — Mr. Syme presented
to the Royal Medical and Chirurgical Society a paper on this subject. In a
former communication upon the remedy of stricture by external incision, the
author endeavoured to show that impermeability was not consistent with the
nature of stricture, and that whenever the urine could pass through the ure-
thra an instrument might be made to do so ; not perhaps at once and with
ease, but always through time and proper management. Though thus certainly
permeable while merely contracted, the canal was undoubtedly liable to com-
plete obstruction in consequence of wounds, and also of sloughing, when it had
been found to constitute a very troublesome subject of treatment by the opera-
tion hitherto employed — viz., cutting upon the point of a catheter passed down

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Progress of the Ileclical Sciences.

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to the seat of obstruction, so as to clear a way for its introduction into the
bladder — a process rendered difficult by the thickness and condensation of the
textures concerned, and also dangerous as well as uncertain by the risk of not
cutting exactly in the proper course of the urethra. Two cases of this kind —
one from a provincial town in Scotland, and another from St. John's, New
Brunswick, in both of which not a drop of urine passed through the urethra for
many months, the urethra being completely obstructed to the introduction of
instruments — having lately come under the author's care at the same time, led
him to reconsider the subject, and devise the following plan instead of the one
usually employed, which for the reasons just mentioned he was unwilling to
adopt. An instrument like the common lithotomy staff, with a groove on its
concave instead of the convex side, being introduced through the fistulous
opening of the perineum, and confided to an assistant, the guide director em-
ployed for the division of strictures by external incision might be passed down
to the seat of obstruction, and while the staff was supported by pressure upon
the perineum to thrust through the opposing substance in the course which it
ought to take if the canal were free, enter the groove, and so pass into the
bladder, when the state of matters would be similar to that of a stricture re-
quiring division after having the director passed through it, so that the opera-
tion might be completed in the same way as upon such an occasion. This
procedure was executed in both of the cases, without any difficulty in one, and
without more in the other than might have been expected from the extreme
degree of injury which the patient had sustained by falling twenty feet, frac-
turing the pubis, having the bladder punctured, &c. &c. The first patient was
dismissed from the hospital perfectly well at the end of seven weeks after the
operation ; the second, passing urine in a full stream, but in general only by
drops through the perineum, appears also to have the prospect of complete
recovery at no distant date. While quite aware that the formation of a new
urethra is much less promising in its result than the enlargement of an old one,
the author expressed his hope that the method which he had proposed would
facilitate the procedure, and lessen the risk of its bad consequences.

Mr. Coulson thought there were many cases in which the plan proposed by
Mr. Syme would not be applicable. There might be a great portion of the
urethra obliterated anterior to the perineal opening, in which case the mode of
propelling the small director would not apply ; or the operator might not
always be able to get the staff from the perineal opening into the bladder, on
account of the tortuous course it would have to take. He had seen many such
cases, in which he considered these difficulties would be almost insuperable.

Mr. Benjamin Travers referred to the fracture of the pubis, mentioned as
occurring in the second case, and said it was a very serious and often fatal
complication. It coexisted with extensive laceration in the neck of the blad-
der. He suggested that the paralysis of the rectum was explained by the cir-
cumstance of the fracture. The difficulty connected with Mr. Syme's opera-
tion would, he conceived, in many cases be to hit the posterior opening, and
push any kind of instrument thence into the bladder. He did not see the
advantage over the old operation practised for so many years past at St. Tho-
mas's Hospital.

Mr. Hutchinson said he had hoped, from the title of the paper, and the
reputation of the author, to have heard a description of some expeditious plan
of getting through those strictures ordinarily termed impassable, and without
any perineal fistula. When a perineal fistula existed the case was a compara-
tively easy one. The operator had but to pass a catheter by the fistula into
the bladder, retain it there as a guide in the subsequent part of the operation,
and then cutting on the point of a full-sized instrument passed by the penis as
far as the obliterated tract, there was no difficulty whatever in making an in-
cision between the two portions of the urethra. The real difficulty occurred in
cases in which no direct fistula from the perineum existed, and the posterior
tract of urethra could not be found. Then again, in cases of obliteration, one
never knew the length of the obliterated tract, and often the induration was
of extreme density. He thought there was some objection to the use of force
with so small an instrument as the grooved director recommended by Mr. Syme,

1857.]

Surgery.

257

from its liability to bend, and to pass out of the proper direction; as he had
once found it do in the course of his own experience.

Mr. Syme, having been requested to do so, explained more particularly the
operation which he had proposed ; and, in reply to Mr. Coulson's objection,
that it would be rendered difficult by the tortuous direction of the fistula, stated
that the passage was always perfectly direct, and also wide, unless perhaps
just at the orifice, since the cause of true obliteration, for which alone the ope-
ration was intended, resulted from either sloughing or wounds, and not from
the gradual extension of purulent matter, as in the ordinary cases of perineal
fistula, which always admitted of remedy, either by dilating or dividing the
stricture that gives rise to them. As to the opinion expressed by Mr. Hutchin-
son, that the operation in question would not be applicable to strictures so
tight and tough as to bend metallic instruments employed for their dilatation,
Mr. Syme again explained that the procedure which he had proposed was in-
tended for the remedy, not of stricture, but of obliteration, and that he believed
the former condition would never be found to require the old expedient of
Gutting upon the point of a catheter, if the introduction of bougies were per-
severingly attempted with skill and care, and especially with such gentleness,
as must entirely preclude the risk of bending a metallic instrument. — Med.
Times and Gaz., March 14, 1857.

44. Excision of -an Enlarged Third Lobe of the Prostate in a Lithotomy Opera-
tion.— The accidental removal of small portions of the prostate in cases of
lithotomy in patients having enlargement of that gland has not unfrequently
occurred. We are not aware, however, that an intentional excision of any part
of it was ever practised prior to the one we now have to notice. About four
years ago we witnessed, at St. Bartholomew's, a lithotomy, by Mr. Lawrence,
in an old man in which the stone wras large, and some delay in extracting it
after it had been grasped by the forceps occurred. At length the parts yielded,
and to the surprise of some lookers-on, a mass of whitish structure fell out
before the stone. This proved to be a portion of prostate tissue, and was about
the size of half a walnut. It was clean and healthy looking, and did not pre-
sent any ulceration, exhibiting the appearance of having been enucleated and
not possessing any covering of mucous membrane. Mr. Lawrence stated that
he did not think the man's prospect of recovery in any way diminished by the
occurrence of it. A good recovery resulted. This is the. only case in which
the writer has ever himself witnessed the accidental removal of portions of the
prostate of any size worth notice ; but it will be in the memory of many mem-
bers of the Pathological Society, that at one of its meetings about a year ago,
Mr. Fergusson stated in the discussion that the occurrence had frequently
happened to himself, and that he had never seen reason to attribute ill conse-
quences to it. The practice of deliberately excising a portion of the gland
must be viewed, however, from quite a different point, and as already said, we
are not aware that any surgeon has heretofore adopted it.

On Saturday last, a man aged 65, moderately stout, and in fair health, wTas
submitted to lithotomy in the theatre of King's College Hospital. Mr. Fergus-
son had more than usual difficulty in seizing the stones, on account of their
lying in a deep hollow behind the prostate. He succeeded, however, in little
more than ordinary time, and two flattish calculi of moderate size were ex-
tracted. He then examined the wound carefully, and, introducing a pair of
straight narrow-bladed lithotomy forceps, grasped something of considerable
size, and then asked for a long probe-pointed bistoury. The latter instrument
was introduced deeply into the wound, as if for the purpose of enlarging the
opening in the neck of the bladder, and then, much, we believe, to the wonder-
ment of all present, turned with its edge towards the median line, and made to
cut very freely across the under part of the first incision. This liberated the
forceps, which were withdrawn grasping a mass the size of a pigeon's egg of firm,
whitish, fleshy structure. This when taken from the forceps proved to be the
third lobe of the prostate. It was conical in shape, and had a broad base, the
latter presenting an oval cleanly cut surface of about an inch across. On its
apex was an elevated surface about as large as a fourpenny-piece, which was

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Progress of the Medical Sciences.

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ulcerated and granulating. Excepting at this spot the mucous membrane was
sound and the structure healthy. No material hemorrhage attended the ope-
ration, and after the man had been removed to his bed, Mr. Fergusson made
the following remarks to those present : —

"The man upon whom, gentlemen, you have just seen me operate, was sent
up from the country some weeks ago, having long suffered from stone. I ascer-
tained the existence of a calculus, and suspected that there were two, and find-
ing also that he was the subject of a greatly enlarged prostate, and had suffered
from difficult micturition on that account, I preferred submitting him to litho-
tomy instead of lithotrity. You would observe that in sounding him with the
staff, which has a long curve, I could not strike the stone, and that I was
obliged to use an ordinary sound with a very short curve in order to do so.
This confirmed my opinion that the stones lay in an unusually deep basin,
behind an enlarged prostate. After the incisions had been completed the
difficulty in sufficiently elevating the forceps to make their blades dip into this
hollow and seize the stones, was considerable. My finger in the wound came
against a large third lobe of the prostate, and the easiest direction in the
bladder was by one side of this, and not over its surface. The second of the
calculi I extracted with the forceps in the sulcus, on one side of this projecting
mass. Having completed the operation, as far as the calculi were concerned, I
recollected how often in treating cases of enlarged prostate I had wished that
it were practicable to remove the source of obstruction by operation ; and it
occurred to me that this was the very case in which to do it. Were the man
to be left with his prostate in the condition in which I had ascertained it to be,
there could be no doubt but that the operation would be but partially success-
ful in relieving his urinary symptoms, however satisfactorily it might have
accomplished its intended object. Believing, therefore, that the excision of the
projecting portion promised more of advantage than it incurred of risk, I de-
termined to practise it. The instruments used were a pair of ordinary straight
lithotomy forceps, and a probe-pointed bistoury, such as is generally employed
for enlarging the opening in the prostate when necessary. I grasped the
prominent lobe firmly by the former, and holding it forwards, sliced it freely
through beneath, taking care to keep the knife close under their blades. I am
not aware that such a procedure was ever before adopted, and must leave it to
experienced lithotomists, who alone are capable of estimating its merits and
risks, to say whether it was a warrantable one. That some additional risk has
been incurred there can be no doubt, as a second wound, and one of consider-
able size, is left to heal. Still, on the whole, I am strongly of opinion that I
have done what the circumstances of the case demanded, and have conferred a
great benefit upon my patient. I would direct your attention to the circum-
stance that there is an ulcer on the most prominent part of the removed lobe,
and would also remark, that the incision made in removing it does not appear
to have joined that made in the lithotomy at the left side. There is, probably,
a narrow bridge of mucous membrane between the edge of the lateral wound
and that made by slicing off the growth. The growth is removed quite to the
level of the mucous membrane of the urethra, and the passage into the bladder
is now most free." — Med. Times and Gaz., April 18, 1857.

45. Vesico -Vaginal Fistula. — Dr. Jas. II. Sawyer, Master of the Coombe
Hospital, and Prof, of Midwifery, relates (Dublin Hospital Gazette, March 1,
1857) the following case of vesico- vaginal fistula in which he operated success-
fully by the plan of Mr. Maurice Collis : —

" On the morning of the 17th of May last, I was sent for to the Coombe
Hospital, in the absence of Dr. Rigland, the Master on duty, and for the first
time saw the subject of the following case.

" Fanny Wilkinson, 21 years of age, remarkably small, and very excitable;
married 15 months ; first child. Admitted into the labour ward at 3 o'clock
P. M. on the previous day. She stated that labour had set in on the 15th, and
that the waters had come away before her admission. On examination the os
was found fully dilated ; head presenting ; pains strong and frequent. On the
ensuing day, as she had not made progress, Dr. Kidd, the assistant to the Mas-

1857.]

Surgery.

259

ters, was sent for. He promptly introduced a catheter, though with consider-
able difficulty, owing to the pressure of the head on the pubes. Having relieved
the bladder, and finding no urgent symptoms, he directed that he should be
sent for if symptoms of constitutional irritation should arise before his return.

" I saw her at 11 J P. M. in consultation with Dr. Jameson, and found her in
a state of exhaustion, with quick feeble pulse, and irritable stomach; the exter-
nal parts were tender, hot, and dry. Under these circumstances, and as the
head had remained stationary upwards of nineteen hours, we decided at once
to terminate the labour. I could not hear the foetal heart, but as the placental
soufflet was evident, and the pupil on duty assured me he had distinctly heard
the fcetal tick a short time previous, I was reluctant to resort to the perforator.
I succeeded, with some difficulty, in introducing the blades of Churchill's for-
ceps obliquely, and after considerable effort extracted a large male foetus. The
patient made a good recovery in all points, with the exception of suffering from
incontinence of urine, which set in about the fifth day after the operation.
The formation of a vesico-vaginal fistula was ascertained ; but, as her general
health was impaired, she was directed to try change of air, and to return to
the hospital after two or three weeks' sojourn in the country.

" She was readmitted on the 1st of July, 1856; and a transverse oval aper-
ture about eight lines in its long diameter, permitting the forefinger to be
passed through it, was ascertained to exist immediately above the neck of the
bladder. The narrowed condition of vagina, combined with the soreness re-
sulting from extensive excoriation, made the examination very difficult. She
complained that the moment she turned in the bed, or assumed the erect pos-
ture, the urine flowed. She said her life was miserable, that she was unable
to earn her bread, and would gladly submit to any operation. I had the ad-
vantage of the advice and valuable suggestions of my respected friends Drs.
Maurice Collis, Churchill, and McClintock; also my colleagues, Drs. Ringland
and Kidd ; and the hospital consultants, Drs. Jameson and Wilmot ; and de-
cided on operating after Mr. Collis's plan, on the 15th. In the mean time I
had made a set of dilators, better adapted to keep the vagina well opened. I
directed borate of soda wash ; and also, with my colleagues' assistance, fully
tried the injection of carbonic acid gas, and Dr. Hardy's chloroform bellows ;
but instead of diminishing sensibility, such aggravated suffering, with in-
creased contraction of the vagina, was induced, that I was forced to put off the
operation until the 25th. Two days prior to that date, I cautiously dilated the
vagina with plugs of prepared sponge, smeared with extract of belladonna,
which proved in this case an admirable anaesthetic. After trying different
positions, I found the lithotomy posture the most convenient, and accordingly,
on the 25th, having previously cleared out the bowels, and secured the hands
and feet, I proceeded to the operation. It was intended to operate under chlo-
roform, but after a few inspirations, the sudden irregularity of the heart's
action compelled us to desist.

" Two dilators were passed, and pressed obliquely upwards and outwards;
then the third, pressing down on the recto-vaginal septum, enabled me to get
a view of the fistula. A full-sized catheter passed through the urethra, and
pressed downwards and forwards, kept firm the posterior margin, and pre-
vented the bladder from coming in contact with the knife. With Baker Brown's
knife I carefully split the vesico-vaginal septum at the posterior lip to the
extent of three lines, carrying the knife carefully around the commissure, and
keeping close to the vesical surface. I then did the same to the lower and
anterior lip, but with greater difficulty, as its aspect was turned from me. The
constant welling of blood and urine compelled me to work very slowly. I
then syringed with cold water, which in some degree repressed the bleeding ;
and with the same needles used by Mr. Collis I introduced four ligatures of
ordinary housewife-thread at intervals of three lines, carefully avoiding pene-
trating the vesical mucous surface. I secured the ligatures over two bars of
gutta percha, instead of gum-elastic, as used by Mr. C, as it is not corroded
by the vaginal secretion. I was most cautious not to draw the threads too
tight, and thus prevented strangulation of the lips embraced between the bars.
The operation lasted about half an hour. She was then placed in bed on her

260

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face, her body well supported by pillows. A long gum-elastic catheter was
passed and secured, and one grain of opium was directed to be given every
third hour. On the fourth day I examined, and was gratified to find the mar-
gins of the wound in perfect apposition, and no suppuration. I cut the liga-
tures, but did not remove them until the following day, that is, the fifth from
the operation. The union was complete, but I did not venture to withdraw the
catheter or act on the bowels until the eighth, when the following mixture was
directed : Olei ricini gvj ; tincturse rhei giij ; confect. amygd. giv ; aquae cin-
namomi ad ^vi. — st. 2dis horis. This acted gently. On the eighteenth
day she was walking about, able to retain the urine, and her only annoyance
was a tendency to pass water frequently. This gradually subsided, and on the
14th August she was discharged in perfect health, and is at present in a good
situation, and, as she declares, as well as ever she was in all her life/7
Dr. Sawyer claims for Mr. Collis's plan the following advantages : —
"First — Facility of execution. Secondly — Probability of speedy union by
the first intention. Thirdly — The prominence of the vesical flaps forming an
admirable barrier to the urine insinuating itself. Fourthly — Comparative free-
dom from hemorrhage. And lastly — If it does not succeed, there will be no
increase of the fistulous aperture, as afteriother plans."

46. Valvular Nature of Strangulated Hernia. — Incarcerated hernia, in Prof.
Roser's opinion, essentially depends upon a valvular mechanism. The ob-
struction of the contents of the intestine in the incarcerated portion arises from
the folds of the mucous membrane lying valve-like against each other, and pre-
venting the passage of gas, fluids, &c. Looking at the complete obstruction
which takes place in the hernia, one might suppose that the parts concerned
are compressed as closely as in an artery when tied. But all observation
teaches us that no such pressure is here exerted ; for while the venous circula-
tion is only partially arrested, the arterial remains uninterrupted. Were it
otherwise, indeed, the intestinal fold would become rapidly gangrenous. The
question is why, if there is space enough to allow of the circulation in the part
to continue, cannot we by pressure return the contents of the intestine.

The nature of the obstruction may be shown by a simple experiment. If a
noose of intestine, containing some fluid or air, be brought within a ring about
the size of the finger, and then pressure be made upon the apex of the noose
so as to force the contents against the compressing body, complete obstruction
to their passage will be found to prevail. And yet a catheter may be passed
beside the intestine, and, by drawing the latter a little to one side, a consider-
able space will be perceived. If pressure be made in front of the encircling
ring, the contents of the intestine are forced back ; but if we press at the end
of the noose, the portion that lies next to the ring is forced against the latter,
and the canal is closed. If we open the noose on its convex side, and fill it
with water, we may observe the valvular disproportion of the intestinal folds,
which resemble the valves of the aorta when acting under water.

Deferring to another occasion the exposition of his theory of the taxis
deducible from these views, Prof. Roser now points out the support they give
to the operation for hernia, without opening the sac — a procedure he regards
as one of the greatest improvements in surgery since the days of Pare. He
believes it has made little progress in Germany and France, as compared with
England, in consequence of the prevalence of a false theory of strangulation
of hernia and erroneous ideas on the surgical anatomy of hernia. In respect
to the first of these, too exaggerated an idea of the constriction that takes place
has been entertained, leading to a belief that the mere dilatation of the ten-
dinous margins could not suffice for the return of the distended and indurated
hernia. The above experiment, which proves the valvular nature of the
obstruction, must surely give more confidence in the efficacy of the external
incision. We have not space to follow the author in his description of the
anatomy of femoral hernia, and which, indeed, essentially resembles that fur-
nished by Cooper. — B. and F. Ned.-Chirurg. Rev., April, 1857, from Vierordt's
Archiv., 1856.

1857.]

Ophthalmology.

261

47. Herniotomy in an Infant seven weeks old. — Mr. Wm. Rayner records
[Lancet, April 4, 1857) a case of strangulated irreducible hernia of the right
side in an infant seven weeks old, attended with stercoraceous vomiting, in
which he successfully operated.

48. Ovarian Dropsy treated by Iodine Injection. — Dr. J. B. Brown related to
the Medical Society of London, the following case of this : J. S., aged 40,
was admitted into Boynton ward on the 5th of March, 1857, under his care.
When eighteen years old, she perceived her abdomen to become more swollen
(but without pain), which gradually increased until she was twenty-five, when
she was tapped, and between seven and eight quarts of clear fluid taken away.
It has since then gradually filled, and produces great uneasiness by its pres-
sure. General health good. On the 11th of March, at 2 P. M., he (Mr. Brown)
tapped in the semilunar line, and drew off sixteen pints and a half of straw-
coloured fluid, slightly albuminous. He then injected six ounces of the Edin-
burgh tincture of iodine into the cyst ; it caused no pain. At half past eight
the same day, iodine was found in the vomited matter, and large quantities in
the urine. On the 12th, she was ve'ry sick and prostrate, and was ordered to
take stimulants freely. On the 13th, she passed a restless night. From this
period she gradually recovered, without any untoward symptom, and left the
hospital quite well, and daily gaining strength.

Dr. Gibb had seen five cases in which the iodine injection had been used.
In three instances it was successful; one had died from peritonitis, and the
other was sinking. In all the five cases the tincture of iodine of the Edinburgh
Pharmacopoeia had been used. — Lancet, May 16, 1857.

OPHTHALMOLOGY.

49. On the Employment of the Ophthalmoscope in the Investigation of Deep-
seated Disease of the Eye. By Holmes CooTe, Ass. Surg, to St. Bartholomew's
Hospital. — The difficulties so often experienced by the surgeon in determining
the exact seat or nature of the different diseases affecting the structures of the
eye posterior to the iris, render any discovery acceptable by which diagnosis
may be facilitated; and hence the ophthalmoscope, which illuminates the in-
terior of the globe and brings before the observer morbid changes in the choroid
coat, or in the retina, heretofore unknown, is attracting at the present moment
particular attention.

Before proceeding to describe some of the cases in which important informa-
tion is gained by the use of the ophthalmoscope, I may remark that the usual
depreciatory cry of obstructive mediocrity has been already raised against this
as against every other novel instrument, either in medicine or surgery. We are
told that the employment of the light injures the eye ; that it shows nothing ;
that what it does show, cannot be rectified. I have often remarked to you that
a precisely similar cry was uttered of the stethoscope, the early general em-
ployment of which is quite within my professional recollection. The same en-
lightened remarks will be made on the next discovery of a similar class, but
experience proves that they do not affect the ultimate success of that which is
true.

I apprehend that one great advantage likely to result from a more accurate
knowledge of the pathology of the deep-seated affections of the eye, will be to
connect ophthalmic surgery more closely with general medicine ; to render it
less a speciality ; and to establish far more scientific and well-grounded prin-
ciples of constitutional treatment. Already have the consequences of scrofula,
gout, rheumatism, syphilis, and Bright's disease of the kidney, on the sight, been
recognized ; but we want the first step in the further inquiry — namely, the na-
ture of the morbid changes in the affected organ.

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Progress of the Medical Sciences,

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Syphilitic iritis is a disease which is generally very easily controlled by pro-
per treatment; namely, the abstraction of blood and the administration of mer-
cury. Occasionally, though rarely, patients do not bear bloodletting. In other
cases, mercury is inadmissible from the beginning; or, at some latter period,
■when other medicines have to be substituted. But at the same time, let it be
remembered, that iritis may run its course without treatment, and leave the
patient very useful vision.

A case which, after the subsidence of the active disease, leaves the patient
with vision impaired for a month or six weeks, but slowely progressing to com-
plete recovery, affords useful matter for ophthalmoscopical investigation.

A young man was under my care in St. Bartholomew's Hospital, suffering
from acute syphilitic iritis, in the month of September, 1856, having neglected
himself for a fortnight previously. His disease yielded to the usual treatment,
but left him with a mist before his sight, which was unfit for any occupation
requiring minuteness. I examined this patient with the ophthalmoscope early
in January, 1857, with the expectation of finding traces of inflammatory deposit
in the choroid membrane. In this, however, I failed ; but behind and to the
side of the crystalline lens, and in the vitreous humour, there were opaque
membraniforra deposits, which prevented the ready transmission of light. Ex-
perience had taught me that ultimately the eyes would recover themselves;
and I expressed myself to that effect in confident terms to the patient. He
presented himself at the hospital on March 12th, when his vision was as perfect
as ever. The morbid deposits had disappeared.

Dr. Heymann, of Dresden, remarks, that in iritis two forms of morbid deposit
are noticed. 1. A sparing exudation from the iris, but with turbidity of the
aqueous humour. 2. Frequently recurring hypopion. In the first form, the
opacities in the vitreous humour were fine, filamentous, or membranous, and
depended upon inflammation of the ciliary bodies, and perhaps of the ante-
rior part of the choroid. In the second, it was seen that the vitreous humour
was turbid, the choroid coat redder than usual, and studded with yellow inflam-'
matory deposits. The veins of the retina were very dark and dilated. In this
form of the disease, the vitreous humour may be occupied by a network of
lymph.

The influence of Bright's disease, or granular degeneration of the kidney upon
the organs of vision, is becoming daily a subject of greater interest. The draw-
ing which I here present was taken from an amaurotic patient of intemperate
habits. The papilla of the optic nerve is swollen ; the branches of the central
vessels of the retina are less visible than natural; there are small and distinct
deposits of lymph about the choroid membrane. Of the history and progress
of this case, I unfortunately know nothing.

Landouzy is said to have first published an account of the connection "between
Bright's disease and amaurosis. But Blodig found only three cases in illustra-
tion of this combination during the five years he studied in the ophthalmic
clinic of Vienna.

At Dresden, Dr. Heymann found in an eye of a patient so diseased: 1. All
the transparent structures normal; 2. The choroid of its usual vascularity ; but
the papilla of the optic nerve was twice its normal size.

In a second case, the vitreous humour was found to be turbid.

In a fatal case, the following post-mortem appearances were observed : Upon
division of the globe, the vitreous humour did not flow out, but clung to the an-
terior and the posterior sections. The anterior part of the choroid showed de-
ficiency of pigment in the choroid, corresponding to external blue discoloration
during life. In the posterior segment, the macula lutea was abnormally marked.
About one or two lines from the entrance of the optic nerve, which was natural,
there was a ring of yellowish white deposits, about twenty in number. By the
aid of a magnifying glu,ss, other and smaller spots were seen in the neighbour-
hood. The microscope showed that these spots were instances of granular fatty
degeneration of the retina, which separated more easily than natural from the
choroid.

Seventeen years ago, long before the microscope was in general use or the
ophthalmoscope invented, the following case came before my notice : —

1857.] Ophthalmology.

263

Thomas P., aged 22, a printer and compositor, a man of intemperate habits,
■was admitted into St. Bartholomew's Hospital, under Mr. Lawrence, with
amaurosis, considerably advanced in both eyes. The sight had been gradually
failing for the last four months, but without heat about the temples or pain in
the head. There had been no dark spots or muscse volitantes. The pupils moved
sluggishly upon exposure to light, which, however, caused no pain.

Feb. 23d, 1840. Five grains of blue pill were ordered to be taken thrice a day.
He was cupped from the neck to ten ounces.

Feb. 24th. He stated to-day that he had of late suffered much pain from
swelling of the legs, which he attributed to his constant habit of standing. He
was suffering from bronchitis of both lungs.

March 1st. He died of the disease of the chest.

Examination of the Eyes after Death. The external appearance of the organs
was natural. The optic nerve was unaltered in appearance, perhaps flatter than
usual ; the transparent structures were healthy, but near to the optic papilla in
both eyes there was an extravasation of blood in the retina visible to the un-
assisted eye.

The bronchi were full of secretion ; the lower part of the lungs was consoli-
dated.

The abdominal viscera were not minutely examined.

I believe that this was a case of Bright's disease, and that in consequence,
those granular changes occurred in the arteries of the retina, which Virchow
has described as common under such circumstances in the capillaries of the
brain.

Sufficient has here been said to show the importance of further investigations
upon the subject. — British Med. Journ., March 28, 1857.

50. Sympathetic Inflammation of the Globe. — Dr. R. Bell, in his quarterly
report of cases occurring at the Edinburgh Eye Infirmary, makes the following
interesting remarks on this serious accident.

" It has long been known to those who are familiar with diseases and in-
juries of the eye, that when one of these organs has suffered severely, its fellow
is very prone to participate in the inflammatory action. This has been noticed
particularly in cases of serious injury, so that an unfortunate individual with
the sight of one eye completely or partially destroyed, we shall suppose, by a
stray pellet from a fowling-piece, by an explosion of gunpowder in blasting, by
a small fragment of steel from the anvil, or some analogous accident, incurs a
very great risk of losing, at no distant period, his remaining, and now doubly-
precious vision, by destructive inflammation lighted up in his other eye. The
sympathetic disease thus kindled is seldom very acute ; but unless arrested by
prompt and appropriate measures, it sooner or later completes its work of
hopeless disorganization. The following case, which occurred to us lately, and
of which the issue has been more favourable than there seemed any reason to
expect, may be adduced, both as an example of the class referred to, and as
affording an illustration of the treatment sometimes, although seldom, beneficial.

" Mrs. S., a healthy-looking person, forty-one years of age, applied for advice
on the 20th of January. About five weeks previously, she had severely in-
jured her left eye, by striking it in the dark against the handle of an outer
door. Her vision was gone, and this seems to have been the case almost from
the moment of the injury. The iris had been lacerated from the pupil to the
ciliary margin at its outer side, and at the same time extensively torn from its
attachments in an upward and outward direction. She mentioned that, although
inflamed and painful for some days, the eye thus sadly damaged soon got into
a comparatively quiet state ; but that, during the last two weeks, the right eye
had caused her much anxiety from the vision undergoing a gradual impair-
ment, to such an extent that she could barely distinguish one person from an-
other, or even find her way along the streets. Upon examining the right eye
thus secondarily affected, we could discover little or no vascularity, but it had
lost all expression, the pupil being greatly dilated and immovable. Leeches
were applied several times to the lower lid, and mercury prescribed in small
but regular doses. No benefit was observed, but rather the reverse, until on

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Progress of the Medical Sciences.

[July

the 11th of February, eight weeks after the accident, her gums became tender,
and a simultaneous improvement took place in both eyes. On the 2d of March,
a gentle mercurial action having been continuously kept up, she could distin-
guish objects of moderate size, such as small phials and boxes on the mantel-
piece, with the eye originally wounded, while with the other she was able to
read type of large size, and to tell the hour on a watch with a white dial-plate ;
but the pupil still continued large and sluggish, and on looking towards the
sky, she was sensible of a number of small dark objects dancing as it were in
the field of vision.

" March 12th. The right eye is regaining its expression, the pupil being
smaller and more movable ; and she can now read with tolerable facility the
smallest print on our dispensary card. This progressive improvement indi-
cates the propriety of persevering with the one-grain doses of blue pill, which
she has been taking twice daily, although there has been very little tenderness
of the gums. We anticipate that the power of vision in the right eye will
eventually be nearly perfect.

"In the foregoing case, the injured eye passed at an early period into a
comparatively quiet and easy condition, although vision appeared to be almost
totally destroyed ; but had the globe continued inflamed and painful, it is very
doubtful if any remedies would have succeeded in saving the other eye. Under
such unfavourable circumstances, namely, one eye inflamed and useless, and
the other beginning to sympathize, two proceedings have been suggested and
carried into effect: both of them, in certain cases, with encouraging success.
The principle upon which they are severally founded is the same ; that of tho-
roughly removing the source of irritation which exists in the eye originally
injured. The first of these operations, regarded by some as the least formi-
dable, consists in cutting off the front portion of the eye, as in the common
operation for staphyloma, and allowing the lens to escape. The wound thus
made speedily contracts and closes, leaving the globe free from irritation and
considerably smaller in its dimensions, but suitable at a later period for the
adaptation of an artificial eye. The second operation consists in removing the
entire globe in the manner recommended many years ago by Dr. Ferrali,1 of
Dublin. Instead of emptying the orbit of its contents, we divide seriatim the
attachments of all the muscles by which the eyeball is surrounded ; when the
latter is readily dissected from its cellular sheath and the optic nerve cut
across. If properly performed, this operation is followed by little or no sup-
puration ; and the textures behind being left undisturbed, the danger, either
at the time or afterwards, is very trifling. "When the globe is thus entirely
removed, there might seem to be an unfavourable condition of parts for the
subsequent use of an artificial eye ; but this objection is more theoretical than
practical.

" Both of these procedures have their exclusive advocates ; but we consider
them both to be good, and applicable to a large number of cases, although one
or other may be preferable under special circumstances. The two cases which
follow, may be related as examples.

"J. D., eighteen years of age, the son of a soldier, spent most of his child-
hood with his father's regiment in India, and has latterly, for some years, been
thrown very much on his own resources, and exposed to maiay hardships and
privations. He is nearly quite blind; and having no better way of livelihood
than that afforded by hawking small wares in a basket, he has the appearance
of being inadequately fed and nourished. Very early in life, he suffered
severely from ophthalmia, probably purulent, in both eyes, and has been liable
ever since to frequent exacerbations and great tenderness. The right cornea
is highly vascular, and quite impervious to light, and, at the same time, so ex-
tremely irritable, that the gentlest attempt to expose and examine it by sepa-
rating the lids causes a profuse discharge of tears. The left cornea is very

1 Dublin Journal of Medical Science, July, 1841. This gentleman is generally
called O'Ferrall by those who quote his very important and suggestive paper, but on
referring to the original source, we find no trace of the prefix.

1857.]

Ophthalmology.

265

nebulous, and permeated extensively at the upper half by distinct red vessels.
The conjunctival lining of both superior palpebras is decidedly granular.
" This was his condition at the time of his first visit.

" Under the use of the solution of diacetate' of lead pencilled upon the granu-
lar conjunctiva, and the pulv. cinchonce with dried carbonate of soda internally,
a great improvement took place in the left eye — the opacity of the cornea gra-
dually clearing away and useful vision returning ; but the right eye underwent
little or no change for the better, and continued to be a source of abiding irri-
tation. It was seldom free from more or less inflammatory action, which the
slightest exposure would aggravate to a distressing and discouraging degree.
All the ordinary remedies having failed to allay and prevent this obstinate
irritability, and the organ itself, so far as vision was concerned, being alto-
gether useless, it seemed necessary to adopt some decided measure, with the
view not merely of removing a vexatious source of pain and discomfort, but of
saving the other eye from that sympathetic inflammation, which we know by
experience to be too often beyond the reach of remedies. In this case, we pre-
ferred the less formidable operation of removing the cornea and crystalline
lens, as likely to be equally effectual with the other procedure, to which we
have alluded, of excising the entire globe. The patient being brought under
the influence of chloroform, the upper half of the inflamed cornea was divided,
as for extraction of the cataract ; the crystalline lens escaped, and then, the
flap being raised, the remaining half of the cornea was easily removed by means
of curved scissors. The wound healed without any untoward occurrence, and
the young man went home free from pain, and with so much improvement in
the sight of his remaining eye, that he now aims at learning some useful occu-
pation.

" W. J., a young woman of eighteen, had severe and obstinate ophthalmia in
early childhood, which not only deprived her almost entirely of sight in the
left eye, but caused very considerable deformity. When she applied for advice
at the Eye Infirmary, a few months ago, the cornea was staphylomatous and
opaque, and presented over one-half of its area a red, vascular, almost fleshy
appearance, caused evidently by inflammatory thickening of the conjunctival
lamina. The eyelids were red and tender ; the lower slightly everted. All
these morbid changes constituted an abiding source of irritation, which made
the other eye weak and watery; so that the patient was very desirous that
something should be done for her relief. The movements of the globe were in
unison with those of the sound eye ; but, as already mentioned, vision was
gone, with the exception of a bare perception of light. Under these circum-
stances, there could be no doubt as to the propriety of an operation ; but
whether the globe should be removed entirely, or merely the projecting sta-
phyloma, was a question admitting of a difference of opinion. We decided in
favour of excising the eyeball, from observing that there was a decided enlarge-
ment of its posterior part, which made it doubtful if the mere cutting off of the
staphyloma would induce a sufficient contraction of the organ after the wound
had healed. The globe was accordingly removed by dividing the various mus-
cles in succession, in the manner previously described. The healing process
advanced very favourably, unattended by much suppuration, and the young
woman is now able to wear an artificial eye, without pain or inconvenience." —
Edinburgh Med. Joarn., May, 1857.

51. Loss of Vision following the bloir of a loliip ; recovery. — E. jST., aged 25,
was admitted into St. Bartholomew's Hospital, under the care of Mr. Lawrence,
on account of a blow across both eyes from the lash of a whip received six days
before his admission. The blow had caused very severe pain : he fell to the
ground, and was picked up unable to see at all. In a few hours, however, he
recovered sufficient vision in the left eye to follow his occupation (that of a
drover) for a few days. The right eye, however, continued blind, and he suf-
fered much from pain across the brow on that side. On admission, the only

1 Vide Edinburgh Medical Journal, November, 1855.

266

Progress of the Medical Sciences.

[July

morbid appearance noticed was that the right pupil was dilated and fixed, and
the cornea surrounded by a faint vascular zone.

The treatment consisted in taking blood by cupping on the temple, and the
administration of mercury to salivation. As the mercurial agency became
established, improvement in vision commenced and progressed steadily, and he
left the hospital, with very fair vision, on the twenty-third day.

Remarks. — In this case the loss of vision was probably due to the cause
vaguely spoken of as " concussion of the retina," a morbid condition, the pre-
cise anatomical nature of which is ill understood, and no doubt varies much in
different cases. From the rapid and decisive improvement which followed the
exhibition of mercury, it maybe conjectured that in this instance there was
some inflammatory exudation following a disturbance in the circulation of the
retina, analogous to that which has been observed in the cerebral circulation
in cases of concussion of the brain, and which produces those minute extrava-
sations described by several English and French writers. As a contrast to
the above, we shall briefly cite another case, in which the lesion to the deeper
parts was of a more permanent character, and the loss of vision irremediable
by medical treatment. In this no antiphlogistic means were indicated, and
nothing remained but to watch the progress of the case, in the hope (which,
however, was not realized) that the absorption of the effused blood might be
followed by partial recovery. — British Medical Journal, March 14, 1857.

52. The Relation of Cataract to Heart Disease — Mr. T. F. Jordan, Demon-
strator of Anatomy at Queen's College, Birmingham, has published [Brit, and
For. Med.-Chir. Rev., April, 1857) a series of nineteen cases in support of the
proposition that non-traumatic cataract is frequently associated with, and in
many instances may fairly be regarded as a result of, cardiac impairment.

A fair examination of these cases justifies, he thinks, the assertion "that
heart disease is in numerous instances found in conjunction with non- traumatic
cataract, and that consideration of the history of the cases where it is found
warrants us to look at it in the light of a cause. It cannot be presumed that
the heart disease is a product of the same cause which induced the cataract,
because then some other and prior cause of both would need to be eliminated.
Such cause it would be difficult to demonstrate. No cause of cataract is known,
unless heart disease be admitted to act as such. That admission being made,
the causes of heart disease are numerous and undoubted.

"The questions which now most naturally arise are these: What extent of
heart disease shall favour the development of a cataractous opacity ? Is there .
any particular lesion of the heart which, more than another, predisposes to the
affection in question ? The cardiac disease exists only in a slight degree —
a degree, however, unmistakably appreciable, whether we consider general
symptoms or physical signs. The cardiac impairment is indeed so limited,
that old age in cataractous patients is a familiar phenomenon to the ophthalmic
surgeon. Nor does the true explanation of this circumstance rest on the infer-
ence that old age is itself a cause of cataract. A large number of cataractous
patients are not old. In one-third of the above cases, the age is between forty
and fifty, while two of the cases are under twenty years.

" It being presumed that cataract is a gradual degenerative change in the
crystalline lens from a partially impaired heart, it is natural to infer that the
causes of so limited lesions would accumulate in old people — in other words,
that younger people would be cut off by more extensive lesions, either of the
heart or other organs.

" Sudden death is not unknown in cataract — occasionally as the mortifying
result of an operation ; but so exceptional is it, that where so extensively a
diseased heart is found as to render either death probable or life uncomfortable,
cataract is one of the results least to be expected. Hence one common cause
of cardiac mischief — Bright's disease — is unknown in cataractous cases, clearly
because Bright's disease leads to other and graver results. Rheumatism, which
may leave only slight impairment of the central organ of circulation, we have
already seen to be a frequent incident in the history of cataractous cases ; pos-

1857.]

Ophthalmology.

267

sibly in the same category with rheumatism, future research may include
influenza, scarlatina, smallpox, and the various fevers.

" In reply to the second question — ' Whether any particular lesion of the
heart more than another predisposes to the affection under consideration?' a
negative would seem the more correct reply. Cataract obeys the general law
which regulates for the most part all the secondary results of heart disease —
namely, that the result is determined rather by the amount than by the precise
locality or nature of the abnormal condition. Of course, the infinite rarity of
disease of the right side of the heart is understood. In the above cases, slight
mitral regurgitation is the cardiac infirmity found in the greater number of
cases. In some of the cases, the mitral and aortic orifices were both partially
implicated ; in one or two, the aortic only. In several of the cases, a fatty
condition of the heart might be reasonably predicated. It will be seen that an
extended prsecordial dulness, without a proportionate increase of the heart's
impulse, was a- not unfrequent phenomenon. Hereditary heart disease was
found in more than half the cases where the hereditary tendency could be dis-
covered. In case No. 19, there had been a chest injury, evidently implicating
the heart.

" It is an undoubted disadvantage that the foregoing conclusions have not,
from entire absence of opportunity, received the confirmation of post-mortem
dissection. But such additional proof, while desirable, is not absolutely essen-
tial. A morbid sound is assuredly an appreciable phenomenon, and cannot
exist without a cause.

" Let us turn now for a moment to the collateral evidence confirmatory of
the inferences above drawn. It has already been stated that the results of
considerable cardiac lesion are not present, and cannot be expected to be pre-
sent, in cataractous cases. The less grave symptoms, however, are frequently
obvious — as vertigo, tendency to faintness, dyspnoea, palpitation. Those, too,
who have mixed much with cataractous patients, must have observed frequently
the peculiarity of their mental states — states not rarely found associated with
heart disease. Extreme loquacity on the one hand, and obstinate taciturnity
on the other, are psychological indices by no means rare. Nor are these results
mere accidental sequences of blindness — they are not found in the blindness
occasioned by injuries.

" Probably much light may yet be thrown on the pathology of cataract by
future microscopic examination of the opaque lens. In one opportunity I have
had of examining a non-traumatic cataractous lens, the microscope revealed
fat globules in the nuclei of the delicate cells covering the surface of the crys-
talline lens, and here and there a few delicate plates of cholesterine might be
detected. May not cataract be the result of a process identical with or analo-
gous to that of fatty degeneration? That fatty degeneration of a portion of
the lens may exist, is proved by the researches of Drs. von Ammon and Schon,
as quoted by Dr. Mackenzie. The former found, in cases of arcus senilis, a
fatty arcus on the corresponding margin of the lens. Dr. Schon has found
both the lens and posterior capsule affected with fatty degeneration."

[Our own observations have not led us to suspect this relation between cata-
ract and heart disease, but the subject is well worthy of investigation, and now
that attention has been drawn to it, it is to be hoped that the conclusions of
Mr. Jordan will be carefully examined.]

53. Ought both Eyes, when Cataractous and equally affected, to be Operated on
at the same time?— My. Mackenzie, in his valuable work, states that his expe-
rience leads him to answer in the affirmative to this question, "if division of
the cataract is the operation to be performed ; but if we mean to extract, I re-
gard it as better to operate on one only, and watch the result before touching
the other. Double extraction decidedly exposes the eyes to greater risk of in-
flammation. If we operate only on one eye and allow it to recover, we may
possibly observe in the course of the operation and recovery some particulars
which will be essentially useful to us in conducting the second operation, or
will even lead us to select a different and more suitable mode of operating for
the second eye. The patient, however, who has recovered from a first opera-

268

Progress of the Medical Sciences.

[July

tion either well, or indifferently, or ill, is often unwilling to submit to a second.
The confinement, abstinence, and depletion, used after a fresh operation, some-
times cause the eye not operated on to fall so much back in the orbit that it is
difficult to perform extraction on it."

Dr. John Sloan, house-surgeon to the Leicester Infirmary, has lately offered
[British Med. Journ,, May 2, 1857) some sensible remarks in relation to this
question.

" I attach," he says, "great value to any statement of Mackenzie's regarding
ophthalmic surgery ; but I believe, and I hope to be able to prove to you, that
his opinions concerning the double extraction are erroneous. Every one who
has seen many cases of disease of the eyes, must be aware of the great sympa-
thy that exists between them, and I was taught to consider the extraction of
both lenses at one sitting a most hazardous proceeding, inasmuch as if inflam-
mation came on in one eye, the other would most probably become affected by
sympathy, and that it was therefore advisable to allow some months to elapse
between each operation. Being a firm believer in this doctrine, I was asto-
nished and instructed by the following cases.

"John Wood, aged 59, a framework knitter, had double extraction per-
formed by Mr. Paget, on the 18th of January, 1856. One eye became violently
inflamed and vision in it was lost, but in the other no unfavourable symptom
appeared, and on the 4th of March he was discharged, able to read pretty well
with the assistance of a proper glass. This case is published in detail at page
246 of the Association Medical Journal for 1856.

" The next was an aged female inmate of the Leicestershire Lunatic Asylum,
who had double cataract, and whose mental aberration was believed by Dr.
Shaw and Mr. Buck to depend in a great measure upon the loss of sight. Mr.
Buck, after a consultation with Mr. Paget, and assisted by him and myself,
extracted both lenses by the double operation. I do not possess notes of the
case, but I learned from Mr. Buck that one eye inflamed, suppurated, and vision
in it was lost, but that the other progressed favourably, and she could see with
it satisfactorily.

"According to the views I formerly held, vision should have been lost in
both eyes in each of these patients. It cannot be doubted that after a single
operation inflammation would as readily have arisen, and loss of vision been
the result in the eye which did badly, as after the double extraction ; and as
the untoward symptoms were confined in each case to one eye, the other not
being sympathetically affected, no mischief was caused ; on the contrary, it
was fortunate for these patients, at least for the sane one, that the double
operation was performed ; because, had one eye been operated on in the ortho-
dox mode, and that one happened to do badly, the man probably would never
have consented to a second operation ; and at this moment, instead of enjoying
the power to read pretty well, he would have been helplessly blind.

" My observations upon these two cases alone did not induce me to renounce
my old notions. I learned from Mr. Paget that his father, whom he succeeded
in the office of surgeon to the Infirmary, always performed double extraction ;
that he himself has always followed the same plan ; and their combined expe-
rience extends over a period of sixty years. I have been told that his late col-
league, Mr. Nedham, did, and I know that his present colleagues, Messrs.
Macaulay and Benfield, do, extract cataractous lenses by the double operation.
These gentlemen are convinced that the greater risk of inflammation after
double extraction is a myth — a plausible hypothesis not founded on facts; and
the truth of which I believe has not been previously questioned in this coun-
try. In no other hospital in the United Kingdom, as far as I have been able
to ascertain, except at the Leicester Infirmary, and at the Birmingham Eye
Institution since its foundation in 1823 by Mr. Hodgson, is it the rule to resort
to double extraction. I know that it has been adopted occasionally by sur-
geons elsewhere ; and it may be argued that if it had been found to be safe it
would have become the usual practice long since. But this argument would
be unjust; because, if this plan has not succeeded in patients under the care
of other medical men, it must be on account of some difference in the mode of
operating or in the after treatment, and it only shows the necessity for them

1857.]

Midwifery.

269

to discover and to remove this difference, and then there can be no reason why
they should not obtain results as satisfactory as have been obtained at the
Leicester Infirmary. I should state that the late M. Roux always performed
double extraction.

" 'That we should only operate on one eye and allow it to recover; as we
may possibly observe, in the course of the operation and recovery, some par-
ticulars which will be essentially useful to us in conducting the second opera-
tion, or will even lead us to select a different and more suitable mode of
operating for the second eye/ is a reason assigned by Mackenzie for preferring
the single operation. Are we not more likely to remember and be prepared to
meet any peculiarities or difficulties encountered in operating on the first eye,
if we proceed to operate on the second after a few minutes, instead of delaying
for some months? We are not obliged to extract the lens from the second
eye in the double operation, if after operating on the first, any other procedure
be considered preferable ; and I cannot see the propriety of watching the pro-
gress towards recovery of one before the other is touched, as, according to my
observations, these cases do not take an unusually erratic or uncertain course,
but the sequence of events in one patient closely resembles that in another,
and we cannot be certain that the progress of the second eye will be similar to
that of the first; on the contrary, it is more likely to be different, because after
some months the patient's general health is likely to be somewhat changed,
and the state of the second eye is occasionally altered materially.

" I have now considered all Mackenzie's objections to double extraction. I
confess I am unable to assign any reason why he should recommend the double
operation for solution, as inflammation is one of the complications to be dreaded,
and the wisdom of waiting some months to remember the particulars of the
first operation, which will aid us in the second, will apply equally well to divi-
sion as to extraction. It appears to me that if it be right to perform a double
operation for solution, it is equally right to perform double extraction. Double
and single extraction being equally free from danger, what are the special
advantages of the double operation ? The patient is only for half the time
confined to his bed and to his room, and stinted in his diet ; there is not the
same risk of his remaining with imperfect or without vision, because if the
first operation succeed well, or even indifferently, he will not unlikely be satis-
fied with what ht has gained, and fearing the risk, refuse to submit to a
second ; or if extraction on the first eye fail, he would probably refuse to have
the second operated upon ; and we must not forget, as already stated, that
* the confinement, abstinence, and depletion, used after a first operation, some-
times cause the eye not operated on to fall so much back in the orbit, that it is
difficult to perform extraction on it.' "

MIDWIFERY.

54. Puerperal Fever. — Prof. Murphy read before the Epidemiological Society
of London (March 2d, 1857), the concluding portion of a paper on this subject.

The author alluded to a former paper on this subject, in which he objected
to the propriety of considering this disease as an inflammation of one or other
of the tissues. He then pointed out, that neither in the mode of the attack,
in the symptoms, in the post-mortem appearance, nor in the treatment, did
puerperal fever agree accurately with peritonitis. A eloser resemblance to
phlebitis was admitted, because both were blood diseases, but he denied that
they were identical. He proceeded to explain his views of the nature of the
disease, that it was the result of a poison, and obeyed strictly all the laws of
morbid poisons. Its action was definite and specific. The seat of that action
was the serous surfaces, especially the peritoneum and uterine veins, chiefly
because of the rapidity of their absorption. He denied that the action itself
should be considered a specific inflammation, although he admitted that in cer-
No. LXVIL— July 1857. 18

270

Progress of the Medical Sciences.

[July

tain eases inflammation maybe excited. The term inflammation was used too
extensively, being made to embrace actions perfectly opposed to each other.
The design of inflammatory action is to preserve or repair organized structure,
yet the term is given to actions that destroy it. Thus, cancerous inflammation,
tubercular inflammation, are expressions sometimes used in such a manner as
to mean that cancer and tubercle were only forms of inflammation. So, also,
in the infantile lung, post-mortem appearances were described as lobar, lobu-
lar, vesicular pneumonia, which were caused by collapse of the lung. The
tendency of a poison is to destroy organization ; it is incorrect, therefore, to
consider its action as a specific form of inflammation, which, whenever it takes
place, is only for the purpose of limiting the action of the poison ; and in this
sense, just as the deposition of tubercle on the peritoneum is accompanied by
peritonitis, so the puerperal poison may excite peritonitis ; but the more power-
ful the poison, the less peritonitis ; and the weaker its influence, the more dis-
tinctly are the evidences of inflammation observed. The action of the puerperal
poison is on the blood ; the quantity of fibrin is increased ; the quality deteri-
orated ; a profuse exudation of morbid fibrin takes place, having none of the
properties of healthy fibrin, it is not organizable ; dissolves into a creamy
substance, which melts into a fluid like pus, and, mixing with serum, forms
the abundant "lactescent fluid" of authors. Exudations are not found in the
veins, because they are not adhesive, but dissolved fibrin, like pus, is found
abundantly. The puerperal poison seems a contrast to the typhus poison, which
destroys fibrin, yet the typhus poison, absorbed by a parturient patient, will
cause puerperal, not typhus, fever. It is the same with erysipelas. The action
of the poison is modified by the dose, as well as by the temperament and constitution
of the patient. Puerperal fever does not attack all indifferently, but selects its
victims. The most important feature of this law is the manner in which the
characters of the disease are modified by the quantity of the poison absorbed.
When it is in excess, the patient may die without any other symptoms than a
fluttering pulse and cold, livid surface. On the other hand, the dose may be so
small, that true inflammation is set up to arrest it, and thus peritonitis, phle-
bitis, or arthritis takes place. Hence the contradictions amongst authors, those
who meet the latter class of cases calling the disease peritonitis, &c, while
those who witness the former stand aghast at symptoms which no theory of in-
flammation can explain. The co-existence of hooping-cough and measles, of
syphilis with erysipelas, proves that two morbid poisons may each set up their
specific actions in the same person at the same time. Erysipelas and puerpe-
ral fever have occurred in the same patient; but the author generally found
erysipelas to precede or follow puerperal fever rather than accompany it. Ery-
sipelas excited puerperal fever; but when the latter was at its height, the for-
mer disappeared. The author objected to the opinion that erysipelas and
puerperal fever were identical, and did not consider those cases described by
Gooch, in which the peritoneum was pale and colourless, as puerperal fever at
all. They might be instances of erysipelas, if this poison ever attacks serous
membranes. The author considered the poison as a contagion just like the
cadaveric poison, which seems so similar to it ; and briefly enumerated the
symptoms of the disease to explain the principle which should guide us in the
treatment. According to its strength, the constitution makes an effort to get
rid of the poison, whether by vomiting or by purging, by the skin, or by the
kidneys. The observation of these efforts led Donat to use emetics; Boer
kermes mineral ; Denman tartar emetic ; and Armstrong salts and senna. If
the effort fail, the poisoned blood accumulates at the centres of the circulation,
which are relieved by a prompt and bold depletion ; for such a purpose, thirty,
forty, even fifty, ounces of blood have been taken with decided benefit; but
depletion should instantly follow the rigor, because if time is lost, the very
same treatment may cnly hasten dissolution. Camphor and turpentine have
been recommended in the treatment of this fever. These remedies are not
only stimulant but anaesthetic, and are useful not alone in supporting the con-
stitution against the attack, but by diminishing pain, they lessen nervous ex-
haustion. Reasoning on these facts, the author tried chloric ether with great
advantage, and recommended it strongly to the consideration of the profession.

1857.]

Midwifery.

271

General rules cannot be laid down for treatment. If the dose of the poison be
a maximum, nothing will save the patient ; if in such quantity that the con-
stitution can make some effort to get rid of it, much of our success will de-
pend upon a close observation of the manner in which the effort is made.
Prompt depletion has saved many a patient. The judicious use of emetics,
purgatives, diaphoretics, and even diuretics, has averted the attack by aiding
a natural effort. . If the dose of the poison be a minimum, then peritonitis, or
phlebitis, becomes prominent, and must be treated as such. Thus what are
called the inflammatory and ataxic forms of this disease, merely signify the
degrees in the dose of this poison. The author alluded to the importance of
prophylactic agents, to ventilation and the improvements lately introduced, to
chlorine as a means of destroying the poison, and to anaesthetic agents as a
means of blunting the sensibilities of the nervous system and diminishing the
activity of absorption. In this sense he considers chloroform extremely valu-
able ; and so far from fearing its influence in causing puerperal fever, he
looked upon it as a preventive. — Lancet, March 28, 1857.

55. Saccharine Urine in Nursing Women. — The presence of sugar in the urine
which has heretofore been regarded as a pathognomonic sign of the disease
Diabetes, would appear, from the researches of M. Blot, to be deprived, to a
certain extent, of its value in the diagnosis of this disease. This gentleman,
in a paper which he has recently laid before the Imperial Academy of Sciences,
states that sugar is always normally present in the urine of women in childbed,
in that of nurses, and occasionally in that of pregnant women. M. Blot, after
having satisfied himself by a chemical examination of the presence of sugar in
the urine, proceeds to state the following facts, as the result of his investiga-
tions upon this interesting subject.

In all women in childbed M. Blot found that it was at the moment of the
lacteal secretion that the sugar first makes its appearance in the urine, in suf-
ficient quantity to be well determined; however, in some cases it may appear
before this period, in which case it is however generally present in small quan-
tity. The amount of sugar present in the urine is exactly in proportion to the
activity or slowness of the lacteal secretion, for when this is abundant the quan-
tity of sugar found in the urine is great, but if, on the contrary, the secretion
is not so, then th^re will be less sugar detected in the urine ; from this we
might, as M. Blot remarks, judge of the value of a nurse by an examination
of the urine.

If it should happen that the lacteal secretion is diminished or retarded by
disease of any kind, the sugar diminishes, or completely disappears from the
urine ; but as health is restored, and with it the lacteal secretion, it again
makes its appearance.

The quantity stated by M. Blot as being present was 8 grammes in 1000
grammes, in the case of a nurse who had suckled for 22 months. Of the wo-
men whose urine was examined, whether in childbed, nurses, or pregnant, none
presented any symptom whatever of diabetes ; on the contrary, their urine was
found to be richer in sugar in proportion as their health was good.

When the secretion of milk ceases, the sugar disappears, but in a variable
time in different cases; thus it does so quicker in those women who do not
suckle, and slower in those, who, having suckled, commence to wean. In
these latter the sugar is alternately present, for it was found one day, absent
the next, but it again made its appearance upon the third. The proportion of
sugar is generally much less than what is found in diabetes; from 1 to 2
grammes up to 12 grammes in 1000 grammes, is about the proportion stated
by M. Blot as being correct ; it may, however, be right to state that this pro-
portion of sugar was found in urine of the morning. In pregnant women
sugar was found present in the urine in about half of those examined.

This saccharine state of the urine of women, which appears from the re-
searches of M. Blot to be constantly under certain circumstances normally
present, will probably also be found to be the case with the females of different
species of mammiferous animals, as M. Blot has already detected sugar in the
urine of the cow in 9 cases which he examined.

272

Progress of the 31edical Sciences.

[July

The author of this paper has promised to prosecute his researches upon the
females of mammiferous animals, for the purpose of ascertaining whether the
same takes place with them as has been shown to occur in women. M. Blot
will lay before the Academy a paper in which he will state the result of his
investigations, which will, without doubt, be of great interest to the physiolo-
gist.—Jfed. Times and Gaz., Nov. 22, 1856.

56. Iodine in Vomiting in Pregnancy. — Dr. J. B. Schmitt some time since
recommended the tincture of iodine in the vomiting of pregnant women, when
this may be regarded as a neurosis. He gives one case in particular, in which
a woman, who had, in consequence of vomiting, had four abortions, and became
pregnant with her fifth child. Two drops of the tincture given every two hours
completely kept the vomiting under, as long as it was continued, the vomiting
only returning when it was suspended. At last, a dose two or three times
daily sufficed. Dr. Eulenberg has also met with a remarkable case in a healthy
woman, 35 years of age, who had suffered from sickness in every pregnancy,
and on this occasion had become much reduced. As she was very susceptible
to the action of medicines, he ordered her — tinct. iod. sp. vini r. giij, 3
drops to be taken in water every three hours. By the second day all the most
distressing vomiting had disappeared, and she was again able to keep water
on her stomach, and in a short time she quite recovered. The modus operandi
of such small doses of the tincture is not very easily explained ; but it is to be
observed, that the iodide of potassium exerts scarcely any influence. It is
highly probable that it only influences the vomiting, inasmuch as this is a
neurosis, an abnormal condition of the nerves of the stomach. In proof of
this, it is also administered with the greatest advantage to hysterical women
suffering from abnormal sensations at the epigastrium as an insupportable feel-
ing of emptiness, or a constant feeling of hunger without appetite. The iodine
acts beneficially in the sympathetic nervous irradiations, even when not con-
nected with pregnancy, but which may depend on suckling, etc. The cardial-
gia and nausea of pregnancy are speedily relieved by it, as well as the vomit-
ing,— Med. Times and Gaz., Nov. 22, 1856, from Berlin Medicin Zeitung. No.
XXV.

57. Sterility. — Dr. Carl Mayer gives the following statement of the patho-
logical examination of 272 sterile women.

In 2, no uterus.
" 60 ) q~ f anteflexions.
" 37 j {retroflexions.
" 35 I og | anteversions.
" 3 j { retroversions.

" 42 inflammatory irritations of the outer genital organs and os vaginae ;

and amongst these, in fourteen women long married, an unbroken

hymen.
" 51 chronic endometritis.
" 25 chronic oophoritis.
" 23 ovarian tumours.
" 12 uterine polypi.
" 6 fibroid tumours of uterus.
" 9 hypertrophy of uterus.
" 1 elephantiasis of outer genitals.

" 6 women, no pathological condition of genitals was found.

" 16 anteflexions — 1, irritation of pudenda ; 4, endometritis chronica; 5,

oophoritis chronica; 3, ovarian tumours; 1, polypus ; 2, hypertrophy

of uterus.

" 13 retroflexions- 1, irritation of pudenda; 6, endometritis chronica; 2,
oophoritis chronica; 2, ovarian tumours; 1, fibroid tumour; 1,
elephantiasis of pudendi.

** 10 anteversions — 2, irritation of pudendi; 3, endometritis; 2, ovarian
tumour ; 1, polypus utero ; 2, hypertrophy of uterus.

" 1 retroversion there was chronic oophoritis.— B. and F. Med.-Chirurg.
Rev., April, 1857, from Virchow's Arch., Sept., 1856.

1857.]

Medical Jurisprudence and Toxicology.

273

58. Involuntary Production of tlie Lacteal Secretion by Electricity. — Dr. A.
Auber, of Macon, was applying the volta-faradic apparatus of Duchenne on
the right breast of a woman who had been delivered seven months, who had
not suckled. The object of applying it was to remove an anaesthesia of the
skin. After the third application, the patient complained of being as she was
after her milk fever, and obliged to cover her breasts, both of which moistened
her dress. On the fifth application, some milk, of which a spoonful was col-
lected, was examined by microscope. It seemed quite similar to that of a wo-
man newly delivered.

Dr. Auber refers to a case in which the lacteal secretion was in like manner
produced by M. Becquerel. He anticipates the possibility of thus making any
woman fit to suckle. — B. and F. Med.-Chirurg. Rev., April, 1857, from L' Union
Medicale, Jan. 20, 1857.

50. Pregnancy in a Two-horned Uterus. — Dr. Lumpe refers to a description,
published by him in 1843, in the Oesierr. Med. Wochenschr., of the autopsy of a
woman who died of metro-peritonitis four days after delivery. In this case the
uterus was found divided longitudinally as far as the os internum. The os in-
ternum and cervix were simple. The right cavity, which contained no ovum,
was enlarged, and lined with a thin vascular decidua.

The following case is a further illustration of this remarkable anomaly. A
woman, aged thirty, who had lived in barren wedlock for ten years, sought
advice on account of menorrhagia and leucorrhoea. Dr. Lumpe found the
external genitals quite normal; the vagina, simple for the first third from out-
let, was apparently divided into two equal canals throughout the upper two-
thirds. The septum presented a complete duplicature of the vaginal mucous
membrane, which was attached in front along the urethra, and hung loose,
flapping like a sail behind; so that during exploration by the finger, it some-
times covered the right and sometimes the left cervix in such a manner, that
on superficial examination, the bicornute condition of the uterus might have
been overlooked. An unequivocal solution was only obtained by using two
fingers. From each half-vagina was felt a completely developed cervix. Both
cervices were of equal size, and on the same level ; they diverged from the point
of union to either side, nearly at a right angle ; they were quite symmetrical,
and provided with a small cross-fissured os, which admitted a sound. No clear
examination of the bodies of the uterus could be made by palpation ; but the
fundus appeared to be bent right and left, exactly as was the case with the
two cervices.

Dr. Lumpe had no opportunity of seeing this case again till some time after,
when he was suddenly called to separate an adherent placenta. In performing
this, Dr. Lumpe found a complete cavity, bent towards the left like a retort;
the placenta was adherent to the fundus ; this had a remarkably long oval
form. The right non-pregnant uterine-horn had been so much hypertrophied,
that it reached nearly half the size of the other. The vaginal portion of the
right horn was quite effaced, and its orifice only marked by a soft, cushion-like
ring.

Labour had come on at the beginning of the ninth month without obvious
cause, and had proceeded naturally and easily under tolerably strong pains.
The child was delicate, but lively. The puerperal period was passed favour-
ably. The involution of the uterus proceeded regularly as in the undivided
uterus. — Ibid., from Wochenbl. Zeitschr. der k. k. Gesellssch. d. Aerzte zu Wien,
August, 1856.

MEDICAL JURISPRUDENCE AND TOXICOLOGY.

60. Death from the Inhalation of Chloroform. — Jos. Allen, Esq., Jun., house-
surgeon to the Royal Infirmary, Liverpool, relates [Lancet, April 25, 1857) the
following case of this which occurred at the Infirmary on the 5th of April
last: —

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"T, N , aged thirty-five, a labourer, of intemperate habits, thin, with

somewhat sallow countenance and anxious expression, was admitted March 18,
under the care of Mr. Edward R. Bickersteth, with an aneurism of about four
weeks' standing in the left popliteal space. It was determined to ligature the
femoral artery, which was accordingly done on the 31st of March, without any
difficulty, the patient being under the influence of chloroform. The same after-
noon he complained of great pain in the limb and numbness; in the evening
the foot became cold, and the next morning it was evident that gangrene of the
limb had commenced. On the 4th inst., four days after the operation, it was
decided, after a consultation, to amputate the limb. Accordingly, about 11
A. M. on the 5th, I proceeded to give chloroform in the ward; that employed
was Duncan and Flockhart's, specific gravity, 1497. It was poured on a piece
of lint, which was then held at a short distance from the nose and mouth.
The patient took it readily, and appeared to come under its influence more
quickly than on the previous occasion. There was a short period of excite-
ment, with some struggling, but no congestion of the face of any note, and
he soon passed into a stertorous condition, taking deep inspirations, the ex-
pirations being short. In about ten or twelve seconds more he was completely
under the influence; breathing tranquil, conjunctivas insensible. The quan-
tity of chloroform was not measured, but he had taken about one drachm
and a half, certainly not more than two drachms. The whole time occupied
in giving chloroform in the ward was about five or six minutes from its first
commencement.

" He was now removed on a stretcher to the operating theatre, and placed
on the table. About two minutes would thus elapse, during which time no-
chloroform was inhaled. He had slightly recovered from its effects, and was
breathing tranquilly and freely; pulse weak, not much affected by the inhala-
tion. About half a drachm of chloroform was now poured on some lint,
which was held to the nostrils, and he then became fully under the influence ;
respirations good; pulse frequent, feeble. The operation was about to be com-
menced, and I was pouring about twenty minims more chloroform on the lint
(having pronounced the patient to be in a fit state), so as to be ready to give
him some more as occasion required, but had not applied it, when, turning
round, I noticed something peculiar in his general appearance, and, on lifting
up the eyelid, found the pupil dilated, and the lid did not elose over on the
removal of the finger; the eyes were slightly turned up. I at once felt for the
temporal artery, but there was no pulsation, and none detected at the left wrist;
the respirations had almost ceased. The head was lowered, eold water was
dashed on the face, and the abdomen struck with the palm of the hand; the
finger thrust into the mouth (there was no action of the heart felt) ; the legs
were elevated, and a wet towel was dabbed over the epigastrium. After one
or two blows the respirations now became better, and seemed good, and in
about two minutes a pulse was felt at the wrist. This continued between
two and three minutes, the respiration being good. His pulse then began
to fail, and in about a minute more the respirations were less. The tongue
was seized with a pair of forceps, and drawn forwards, and artificial respira-
tion tried, and ammonia held to the nostrils ; but he was becoming livid in the
face, so the Ready Method was at once adopted, and this produced apparently
a few natural respirations. But the pulse had gone, and in about two minutes
more there was no breathing save artificial. About the time that the pulse
stopped, there was a convulsive movement of the muscles of the leg, and a
slight clamminess of the skin succeeded. The Ready Method was continued
for half an hour, and galvanism tried, but without avail. From the time he
was placed on the table to his death, or the cessation of natural respiration,
about ten minutes elapsed.

" Autopsy, twenty foe hours after death. — Post-mortem rigidity remaining. On
opening the skull the vessels of the dura mater contained fluid blood, but were
not disturbed ; the blood soon coagulated on exposure to the air. Some little
fluid in a few of the subarachnoid spaces. Brain healthy, tolerably firm, and
pale ; medulla oblongata and upper part of spinal cord healthy and firm. On
opening the chest the lungs were slightly collapsed; pleura healthy; pericar-

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275

■clium contained normal amount of clear serum ; on parietal layer were several
white patches, especially posteriorly. Heart: of natural size ; right side flabby;
left side contracted, but not firmly ; right auricle and ventricle both contained
some fluid blood (which afterwards coagulated on exposure), and a small soft
clot ; valves healthy ; left auricle and ventricle contained some fluid blood and
a small coagulum, but all the cavities were comparatively empty ; the walls of
the right ventricle were thin, and the muscular tissue of this and the left ven-
tricle had a dingy, unhealthy look, and very readily tore. Under the micro-
scope no oil-globules were detected; the fibres, however, were not well marked,
and in many the true muscular tissue appeared to be wanting, its place being
supplied by condensed cellular tissue. Pulmonary arteries contained coagula.
Lungs: healthy, but tissue compressed ; emphysematous towards free margins;
no congestion of any note. Bronchi healthy. Liver: rather larger than natu-
ral; had a rotten, oily look; and on examination under the microscope numer-
ous oil-globules' were seen. Gall bladder healthy. Spleen : very pulpy and
soft, but of natural size. Kidneys: left, small, from arrest of development, but
healthy; right, healthy, but congested. Aorta: both thoracic and abdominal
coats healthy. Vena cava: somewhat distended; healthy. Stomach and in-
testines: pale, but healthy. Blood: nothing particular noted about it.

" Remarks. — The chloroform was administered in this case in the same way
as I have been constantly in the habit of giving it to other patients — viz., in
small doses of about half a drachm or less at a time, on a piece of lint, so' as to
bring the patient gradually under its influence, and whenever any struggling
or any congestion of the face, &c, takes place, suspending it for awhile, or
giving it diluted with a large quantity of air; so, also, whenever the breathing
becomes stertorous. This patient, on the previous occasion, took a much larger
quantity of chloroform, and there was a good deal of excitement produced and
stertorous breathing, before he became fully under the influence, but he soon
recovered from the effects, so that it had constantly to be kept up. He had no
bad symptoms attributable to the chloroform afterwards.

" He apparently sank from syncope, or cessation of the heart's action, for
his respiration had been good just before he changed, and it continued for a
second or two, though faint, when the pulse had stopped; and after the respi-
ration had been restored, and was pretty good, the pulse was very feeble, and
ceased two minutes before the respiration. The Ready Method acted very well ;
and if the sinking had been due to the respiratory system, it would have in all
probability averted the melancholy event. The post-mortem appearances bear
out this view — viz., of death from syncope, from the little blood found in the
cavities of the heart, and the absence of congestion of any organ, so frequently
noticed in these cases of death from chloroform ; in fact, there appeared to be
no excess of blood in the whole system. What, then, was the cause of the
syncope? Was it the chloroform ? This it is impossible to answer for certain.
Doubtless the chloroform would have the tendency to produce it ; and being
under the influence of chloroform, it was more difficult to rouse the patient; in
addition to which the muscular structure of the heart was not healthy. We
have, moreover, to consider that the patient had only a few days before under-
gone an operation, and was suffering from gangrene. Yet, notwithstanding-, I
believe there is only one conclusion to be drawn — viz., that he died from the
effects of the chloroform.

" As to the treatment: as the patient was unable to swallow any brandy, the
application of ammonia to the nostrils, the lowering the head and elevation of
the extremities, were the most suitable remedies, with the sudden application
of the cold hand, or a wet towel, over the epigastrium, to rouse the system and
excite respiration. This latter remedy had the desired effect for a time; after-
wards the maintaining artificial respiration, by the Ready Method, in the hopes
that the system might recover itself; and endeavouring, with the galvanic cur-
rent, to excite the heart's action, as well as the respiratory movements. It is
a question whether we do not discard too much in such cases the use of gal-
vanism."

61. Death from Amylene. — Dr. John Snow gives the following aceount of a
case in which death followed the administration of amylene.

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" Mr. Fergusson requested me to assist him on the 7th instant, in the case of
a gentleman on whom he was about to operate for fistula in ano. The patient
was 33 years of age, and was in good health, with the exception of the local
complaint, although he had lived somewhat freely. Mr. Fergusson examined
the patient's chest the day before the operation, and found the sounds of the
heart to be normal. I felt his pulse just before he began to inhale. It was
natural, but somewhat accelerated, as usually happens just before an operation.
He was lying on his side in bed. About six fluidrachms of amylene were put
into the inhaler (I never intentionally use all I put in, but add more before the
paper becomes dry), and he breathed steadily and gently. The valve was
gradually advanced over the opening in the face-piece till it about three-quar-
ters covered it, and the patient appeared to become quietly unconscious in
about two minutes. He breathed quickly for a few inspirations just as he ap-
peared to become unconscious. Just after this, Mr. Fergusson came and felt
the patient's pulse, and he says it was very good. I felt it also. I looked at
my watch at this time, and it was two minutes and a half or two and three-
quarters from the beginning of the inhalation. Mr. Fergusson commenced to
use the probe, and, finding the patient did not flinch, he began to use the bis-
toury. Mr. P. C. Price assisted at the operation. I held the patient's thigh
with one hand, as I often do in such an operation, lest he should flinch. He
did not flinch, however, but kept his limbs tense, without moving them. Just
at this moment I observed that the valve of the face-piece, which I had left
three-quarters covering the opening, had moved so as to cover it entirely, but
I cannot say whether or not the patient had taken an inspiration a little
stronger than I intended, and thought nothing of the matter, as I have fre-
quently had to close the valve completely in giving amylene. It could not,
however, have been many seconds in that position, for I paid no attention to
the operation, except so much as was requisite to guide me in what I was
doing. The inhalation was discontinued at the moment I have mentioned,
and on looking round directly after I found that the operation, which had ap-
parently been but one incision, was finished. I now began to feel for the pulse,
more out of constant habit, and from a scientific curiosity, than from any sup-
posed necessity of doing so. Although it had been good only half a minute
before, I could not find it in the left wrist, and only a slight flutter in the right
one. His breathing was, however, good, indeed quite natural, and he did not
seem even to be very insensible, for there was some motion both of his features
and limbs as if he were about to awake. I watched the patient with great
anxiety, thinking that surely his good and natural breathing would restore the
pulse, and feeling that, at all events, this superseded any other measures at the
moment. In two or three minutes, however, he seemed to be getting more in-
sensible; he did not wink on the edge of the eyelids being touched, and the
breathing was getting slower and deeper. I called Mr. Fergusson's attention
to the patient, and both he, who was preparing to go away, and Mr. Price, who
had all the time been standing by the patient, were surprised to find that any-
thing could be wrong, as they had seen the patient going on apparently so
well, not only during the inhalation, but after it was discontinued. They
dashed cold water in his face, which did not seem to have any effect. His
countenance was now livid, and his breathing of a gasping character. It soon
began to leave off, with the exception of deep, distinct, gasping inspirations,
and we, therefore, began to perform artificial respiration, by Dr. Marshall
Hall's method, placing him in the prone position, and bringing him partly
round, while Mr. Price kept the mouth open. The air could be distinctly
heard passing through the larynx during this motion. We also tried pressing
on the chest, with the head on one side and the mouth open, which answered
very well as regarded the ingress and egress of air. Inflation from mouth to
mouth was tried, but did not seem to answer so well. Although deep gasping
inspirations were made by the patient till fully ten minutes had elapsed from
the failure of the pulse, the measures used had no effect ; I believe that I heard
a feeble motion of the heart even after this period ; and, as Mr. Fergusson
perceived a slight pulsation at the same time in the right wrist, I was probably
not mistaken. There were no further signs of life after this, although the

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artificial respiration was continued for a long time. I am quite sure as to the
length of time respiration continued after the failure of the heart's action.
The pulse ceased to be distinctly perceptible at ten minutes before five, and
the patient was still breathing at five o'clock. He had not taken food for some
hours, but drank a pint bottle of ale a little while before the operation. A
good portion of amylene remained in the inhaler after it had been uncovered
for an hour and a half.

There was an examination of the body forty-eight hours after death. The
body was rigid. There was a good amount of fat beneath the integuments.
The cartilages of the ribs were ossified. The lungs were large, and did not
collapse ; they completely filled the cavity of the chest, and seemed by their
texture to be emphysematous, although there were no large cells on the sur-
face. There was a little congestion at the posterior surface of the left one;
otherwise they were not very vascular. There was a little clear fluid in the
pericardium. There was a good deal of fat on the surface of the heart, which
was somewhat larger than natural. It was removed by cutting the great ves-
sels before it was opened, and, in removing it, three or four ounces of dark-
coloured fluid blood escaped. The right ventricle was somewhat dilated, other-
wise the heart was healthy ; the walls of the left ventricle seemed very thick,
but it was contracted, so as almost to obliterate the cavity. The liver was
vascular, dark-coloured, and friable. The stomach was healthy, and contained
only a little mucus. The other organs were not examined. There was no
odour of amylene in the body.

Although I used every care and attention in this case which seemed to be
possible, 1 cannot attribute the patient's death to any other cause than the
amylene. The failure of the pulse took place at the moment when the opera-
tion was performed ; but, as the patient was unconscious, I can hardly connect
the two events, or I might illustrate the case by one which I witnessed two or
three years ago. In that case, the surgeon performed an operation for fistula
before the patient was unconscious, in mistake, and immediately afterwards
the patient, a youngish man, went through the process of apparently dying;
but, fortunately, gave a gasp and recovered. ' He then told us what I very well
knew, that he had felt the pain of the operation. He said that he did not com-
plain, as he expected to feel it, for he could not believe what had been told him
about chloroform.

I believe the patient had emphysema of the lungs. There was no such force
used in the artificial respiration as could permanently dilate the air-cells, and
the dilatation of the right ventricle indicates some chronic obstruction to the
pulmonary circulation. In commenting on a case of death from chloroform,
which occurred at the Mauritius, I made the following remarks : " The reporter
considered that the emphysema was the cause of death, by interfering with ex-
piration, and thus detaining the vapour; and it must be admitted that, if the
vapour were not sufficiently diluted with air, the emphysema would increase
the danger. At the same time I have had practical experience to show that
when it is sufficiently diluted, it may be safely inhaled, even in extreme cases
of emphysema."

The continuance of respiration so long after the heart is paralyzed, in the
case I have related above, and in some deaths which have happened from
chloroform, is an extremely curious event. It proves that some little circula-
tion must be still going on through the brain, and, in fact, the slight fluttering
pulse and feeble sounds of the heart once or twice heard indicate this ; but,
under these circumstances, why does not the heart itself recover? If the cir-
culation were going on in the coronary arteries, it might be expected that the
blood from the lungs, which has been aerated by respiration and freed from the
narcotic vapour, would restore the action of the heart. Dr. Cockle has ex-
pressed the opinion, which is very probable, that the blood enters the coronary
arteries in a retrograde manner, during the diastole of the ventricles, when the
aorta, and such great arteries, are contracting on their contents; if so, with a
very feeble circulation, the elasticity of the aorta, perhaps, cannot sufficiently
act to cause a backward current, and perhaps, also, the over-narcotism of the

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heart is itself an obstacle to the coronary circulation by the congestion in the
capillary system which always attends on narcotism.

The above accident happened in the 144th case in which I have administered
amylene. It is impossible to form an average from a single case. I do not
know any reason why an accident like the above might not have occurred in
one of the early cases in which I was giving chloroform, or, on the other hand,
why I might not have been able to go on for four or five years at a time ad-
ministering amylene, without any approach to an accident. The investigation
of this agent has been actively taken up on the Continent, and the extent to
which it will ultimately be used will probably not be much influenced by the
occurrence I have had to relate. — Med. Times and Gaz., April 18, 1857.

62. Poisoning from the Application of the Belladonna Plaster to the Skin. —
The following case, recorded by Dr. Wm, Jenner [Med. Times and Gaz., Nov.
22, 1856), is of practical value as enforcing a caution against the repeated ap-
plication of belladonna plasters to the same surface.

"Mr. Th. having suffered for some time from pain in the back, palpitation,
and dyspeptic symptoms, consulted on October 4 a physician, who prescribed
nitro-muriatic acid, and a belladonna plaster, 9 inches by 6 inches, for the back.
The plaster produced a crop of pustules, though the patient was not aware
of it.

At 10 A. M., October 14, he removed the old plaster, and applied on the same
part, now the seat of the pustules and of a few minute ulcers, a new one of like
size.1 At this time he felt particularly well. Soon after ten he left home.
Between eleven and twelve, while in the city, he noticed that his tongue and
throat were extremely dry, and that his tongue was covered with a white,
clammy fur, which he could pull off in strings. The sense of dryness and dis-
comfort of the tongue and throat were most distressing, and such as to impede
articulation. At the same time he was affected with extreme desire to mictu-
rate, though he could pass only a few drops of perfectly colourless urine. From
this time till he lost consciousness his desire to pass urine was constant ; where-
ever he could retire he did so, but succeeded in expelling from the bladder, with
considerable effort, only a few drops of colourless fluid. The sense of dryness
of the tongue and throat continued to increase, and he soon began to feel a
little confused in his head, so that he was fearful people would think he had
been drinking. He transacted all his business correctly, though at his office,
where he was between two and three o'clock, it was observed that there was
something strange in his manner and speech. Here he drank some water,
which seemed even to increase his sense of dryness of the tongue. He drove
himself home, which he reached about three o'clock. His mind, by this time,
was a good deal confused, and, feeling himself unable to pay his men, he placed
the money he had just drawn from the bank in safety in his own room. Soon
after he had, five or six times in quick succession, convulsive catchings of the
extremities, face, and trunk, such, he says, as animals have when bitten by
venomous serpents ;2 then his mind began to ramble, and his ordinary medical
attendant, Mr. Knaggs, of Kentishtown, was sent for. When Mr. Knaggs
arrived, Mr. Th. was very delirious, but still recognized him.

" I saw the patient about 6 P. M., at Mr. Knaggs' request. "We found Mr.
Th. much worse than when Mr. Knaggs had left him. He was standing by
the bedside, supported by two men; he seemed to exercise very little control
over the lower extremities, and to have very little power in them. It was clear
that he must have fallen to the ground had he been left without support. He
leaned a little to the right, as though the right side were weaker than the left ;
but then those about him told us that shortly before he had inclined to the left
side. He was led, at my request, to the opposite side of the room, both legs
dragged, but neither one more than the other. He was restless in the extreme,
and would not lie down for an instant; his hands were in constant motion ; he
seemed as if he were busy moving some light objects. Occasionally, he raised

1 Both plasters were obtained from Mr. Bell, Oxford Street.

2 Mr. T. is employed in the Zoological Gardens.

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Medical Jurisprudence and Toxicology.

279

his feet alternately some distance from the ground, as one does in ascending
stairs. He moved his mouth incessantly, evidently with the idea that he was
talking; but the sounds that he uttered were inarticulate, and altogether unin-
telligible. He paid no attention to those about him ; in fact, seemed uncon-
scious of their presence, only now and then, when addressed in a loud voice,
he stared at the speaker for an instant, like one suddenly aroused from a sound
sleep. Once he laughed, when bid to put out his tongue, and in the most rapid
manner protruded it, and then as quickly withdrew it. There was a little de-
viation of the face to the left, though not more than is natural to many adults,
and is, I think, proper to Mr. Th. The pupils were very large; when the can-
dle approached them, they acted equally, but imperfectly and sluggishly. The
head was warm, but not warmer than the surface generally ; the face was a
little flushed. There was no throbbing of the vessels of the neck or head.

" The pulse was between 80 and 90, and regular. The heart's action was
tolerably strong; the left ventricle was hypertrophied, and a loud, double, endo-
cardial murmur was heard at the base.

" The history of the symptoms before Mr. Knaggs saw the patient was only
obtained from him after his complete recovery, and so some doubt was at first
entertained as to the nature of the case. Still, as the symptoms agreed with
no disease of the brain or meninges with which I was acquainted, while the
majority were such as occur in poisoning with belladonna, we thought it highly
probable that they were due to absorption of belladonna by the skin. The
plaster was accordingly removed at once, and the surface greased and washed,
and clean linen put on, some of the belladonna having passed on to the shirt.
A blister was applied to the back of the neck, ancPan aperient, with five grains
of sesquicarbonate of ammonia, directed to be given every two hours. The
first dose of the ammonia produced such decided improvement, that Mr. Knaggs
gave a second dose in half an hour; this was followed almost instantly by per-
fect consciousness.

" The next morning Mr. Th. was able to arrange his accounts, though he had
not slept for an instant. He had no sleep the following night, and his memory
for two or three days was very defective. He does not remember anything
that passed between Mr. Knaggs' first visit (and even of that he has only a
dim recollection), and his return to consciousness, about 10J or 11 P. M. He
is now quite well, with the exception of slight dimness of vision, and dilatation
of the pupils, and a consciousness of a little impairment of memory. There
does not seem to have been any eruption on the skin, excepting the pustules,
nor any itching on the surface."

63. A New Poison. — M. De Luca recently communicated to the Imperial
Academy of Sciences, the discovery of the poisonous principle of the Cyclamen
Europceum, or common sowbread. This tuberculous plant has long been used
in medicine as a violent purgative, and externally as a resolvent and a remedy
for the earache ; but it was not known that it contained a powerful poison, pro-
ducing effects not unlike those of the curara, which the Indians of the Rio
Negro use to poison their arrows with. M. De Luca obtains it by digesting the
root for forty-five days in alcohol, then pounding the root, digesting it again in
a fresh quantity of alcohol, and repeating this process until the pulp has lost
its acrid taste. All the tinctures thus obtained are then left to spontaneous
evaporation in a cellar. At the end of about forty days a whitish substance is
deposited, which, after being repeatedly washed in boiling alcohol, is left to
dry in the dark. The cyclamine, or vegetable base of the cyclamen, thus pro-
duced, is white, opaque, and brittle, and emits no particular smell ; it absorbs
the humidity of the air, becomes transparent and gelatinous in water, and as-
sumes a dark colour when exposed to the action of light. It is a curious fact
that, while pigs pan eat any quantity of the root with impunity, not only the
active principle itself, but even the natural juice of the root, acts as a poison
on small fish, if mixed with the water in which they are in the proportion of 1
to 3000. Four grammes of the juice injected into the trachea of a rabbit caused
it to die in convulsions in the course of ten minutes. Bromine appears to be
an antidote to this poison, or at least to mitigate its effects considerably ; it

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has the same neutralizing power over the curara poison. — Med. Times and
Gat., April 25, 1857.

64. Alleged Mental Unsoundness associated with Old Age. — A somewhat sig-
nificant and important case relating to alleged mental unsoundness, associated
■with old age, has within the last week been brought before one of our equity
courts of law. We refer to the case reported in the Times of the 27th ultimo.
The matter came before the Lords Justices, a petition, supported by numerous
affidavits, having been presented to the Court of Appeal for a commission of
lunacy, to inquire into the alleged lunacy of an aged gentleman, of the name
of Taylor, resident at Hirwan, in Glamorganshire. We append the Times1
report of the proceedings: —

"The subject of the application is Mr. Philip Taylor, an old gentleman, a
retired grocer and draper, who is possessed of considerable property and resides
at Hirwan, in Glamorganshire, and its object is to place him under the care
of the Court of Chancery as a person of unsound mind, and incapable to manage
his affairs. The petitioners are Mr. David Evans, of the same place, and Helen
Eliza his wife, the niece of Mr. Taylor. The petition alleged that ever since
April, 1856, he had been of unsound mind; that Mrs. Evans, when eighteen
years of age, came to live with him (he being a widower), and so remained
from 1841 to 1851, when she married ; but in 1847 and 1856 he executed wills
leaving her the bulk of his property ; that Mr. and Mrs. Evans lived with him
from October, 1855, to September, 1856, after which they removed to a house
next door, but all lived together as one family ; that on the 5th of December,
1856, Mr. Taylor left and we&t to reside with Mr. and Mrs. David Williams in
another part of Hirwan, the latter being a niece of the late Mrs. Taylor, and
that he on the same day was prevailed upon by them to execute a will in favour
of Mr. and Mrs. Williams, the gentleman first called in to write it having
refused to do so on the ground of the testator's incompetency. This petition
was supported by many affidavits. The old gentleman had been examined by
seven medical men, three of whom pronounced him of unsound mind, and four
declaring him perfectly sane, but admitting him to be of impaired memory. In
this state of the medical poll, there being a majority of only one, the Lords
Justices determined to send a physician on their own behalf, and Dr. Forbes
Winslow was deputed to perform the delicate task of examining the supposed
lunatic, and to report the result of his experience to the Court. The report,
dated the 30th of March last, concluded with this passage: —

" ' I can detect no morbid alienation of affection in Mr. Taylor's mind. His
memory is defective, perhaps more so than is generally the case at his age, and
his mind is occasionally confused when questioned closely upon minute points
of business, and when suddenly requested, without any assistance from his
books, and papers, to give a detailed account of his somewhat complicated
property ; but this I conceive cannot be considered as satisfactory evidence of
mental unsoundness such as to justify the application to the Court for a com-
mission of inquiry. If evidence similar to this were generally considered suffi-
cient to warrant the protection of the Court of Chancery on the plea of mental
unsoundness, no aged man in the kingdom, with a memory somewhat impaired
by age or bodily infirmity, would be safe from the suspicion of insanity or
mental incapacity. During my five long interviews with Mr. Taylor, I sub-
jected his mind to a most rigid examination, and applied to his understanding
all the well-established tests with the view of thoroughly analyzing the sanity
of his intellect, and, with the exception of an impaired memory upon matters
of account, I could detect no one symptom that would justify the allegation of
insanity. I therefore have the honour to report to your lordships that I am
clearly of opinion that Mr. Philip Taylor is a person of sound mind, and capa-
ble of managing himself and his affairs/

" Mr. Cairns supported the petition.

"Mr. W. M. James and Mr. Freeling, who appeared for the alleged lunatic,
were not called upon.

"Lord Justice Knight Bruce. — Let the petition be dismissed.
" Lord Justice Turner. — Certainly.

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281

" Mr. Cairns hoped their lordships would see from the affidavits that Mr.
and Mrs. Evans only performed a duty in seeking the protection of the Court
for this aged relative. Had they not interfered, and anything serious had
happened to him, they would have been blamed.

Lord Justice Knight Bruce. — Well, it is no doubt very disagreeable that an
aged and wealthy uncle should suddenly exhibit a preference for his wife's
niece at the expense of his own. There is, however, no help for it. Aged
and wealthy men will be capricious. You have the old gentleman's deeds.
Will you give them up?

" Mr. Cairns said his client would deliver them to Mr. Taylor, but some
person should be present to attest the fact.

"Lord Justice Knight Bruce. — Why should this invalid gentleman be
troubled by two sets of attorneys ?

"Mr. W. M. James. — Only to give some colour to the idea that he is not
competent to receive and take care of the deeds.

"Lord Justice Knight Bruce. — Let the deeds be delivered upon the written
receipt of Mr. Taylor. Our view of the evidence is such as that he is perfectly
competent to give such a receipt."

This is not the first attempt that has been made (but happily frustrated), in
the Court of Chancery to establish lunacy against persons advanced in life, the
only justification for such a proceeding being an enfeeblement of memory, and
an inability, on the part of the alleged lunatic, to give an off-hand, succinct
account of the nature and extent of his pecuniary affairs. Dr. Winslow asks,
"What old man in the kingdom is safe from the grasp of mercenary and de-
signing relatives, if evidence of this character is admitted in our courts of law
as proofs of mental unsoundness ?" There is, no doubt, a form of mental
decay and incapacity, associated with premature old age, occasionally presents
itself, which requires, to meet the justice of the case, a modified kind of legal
protection ; but it would be the height of cruelty to make such persons the
subject of a formal commission of lunacy, thus casting not only upon them-
selves, but upon their descendants, the imputation, slur, and odium of insanity.
Dr. Forbes Winslow has frequently reverted to this subject in the Psychologi-
cal Journal; and we believe it is the intention of this gentleman to bring the
question in detail before the medical and legal professions, with the view of
obtaining some alteration of the law respecting cases of mental incapacity,
often associated with old age, which cannot, without a gross and unjustifiable
abuse of terms, be designated in legal phraseology as either "insanity," " idiocy,"
"imbecility," or "unsoundness of mind." We hope Dr. Winslow will not lose
sight of this deeply interesting and important social as well as medico-legal
question. We have often been much impressed with the unfair mode adopted
by persons desirous, coute qui coute, to get at evidence to establish mental un-
soundness in certain cases. If an impairment of the faculty of memory, and
an inability to give minute and accurate details as to the nature, extent, and
value of property, are to be held as valid evidence justifying the interference
and protection of the Court of Chancery, there are, we fear, living at this
moment, hundreds, nay, thousands of aged and infirm old gentlemen and
ladies, under the happy delusion that they are perfectly sane and mentally
sound persons, fully competent to be at large, and quite fit for the management
of themselves and their affairs. Let any psychological expert examine any one
of these old gentlemen and ladies -for the purpose of making an affidavit in
support of the allegation of lunacy, and nine-tenths of them will easily succumb
to the insane test, if impaired memory as to minute matters of detail connected
with property is sufficient to establish the theory of mental unsoundness.
Society must be protected from such a dangerous doctrine and so lax a practice.
Dr. Winslow has invariably, whenever called upon, as he often is, by the Court
of Chancery to investigate these delicate questions, taken high vantage ground,
always fighting the battle of persons advanced in life, who merely on account
of a decayed memory are alleged to be of unsound mind, and fit subjects for a
commission of lunacy.

Our readers, no doubt, have a vivid recollection of the remarkable and noto-
rious case of Mrs. Catherine Cumming, and of the great efforts made by Drs.

282

Progress of the Medical Sciences.

[July

Winslow, Conolly, and Barnes, to protect this aged lady from the accusation
of mental incapacity, as well as from the kind but misdirected attention of her
family. The celebrated Eyre Arms jury, unhappily for Mrs. Cumming, and
unfortunately, as it has turned out, for her estate, ignored the evidence of Drs.
Winslow, Conolly, and Barnes, and listening to the persuasive eloquence of
a brilliant advocate (Sir Frederick Thesiger), brought in a verdict of insanity.
"What has been the result? Not one penny of that large property has, as yet,
passed into the pockets of any one member of her family ! Is this to be con-
sidered as another illustration of retributive justice? Mrs. Cumming was no
more insane than is Mr. Philip Taylor. Fortunately for this gentleman's
peace of mind and property, the Lords Justices have provokingly nipped his
alleged lunacy in the bud. — Lancet, May 2, 1857.

65. Transformation of Amygdaline into Hydrocyanic Acid within the Body. —
Professor Kolliker and Dr. Muller, of Wurzburg, have arrived at the following
results from a series of experiments : 1. Amygdaline and emulsine introduced
separately into the circulatory system by different channels, form prussic acid
in the blood. 2. When the quantity of these substances is sufficiently large,
death soon occurs ; it takes place more slowly with weaker doses. When
amygdaline is first injected into the blood, and emulsine an hour afterwards,
death speedily occurs. 3. When emulsine is first injected, and amygdaline
forty-five minutes afterwards, death is retarded. Is the emulsine changed in
the 'blood, or rapidly excreted? 4. Poisoning is not produced by injecting
amygdaline into the blood, and emulsine into the alimentary canal. The emul-
sine, therefore, does not pass from the blood into the digestive canal, at least
not without some change; on the other hand, it is not found in the intestines
on post-mortem examination. 5. When emulsine is injected into the blood,
and amygdaline into the intestines, poisoning occurs, though slowly. Death
has been produced by introducing amygdaline into the digestive canal of rab-
bits, without any emulsine. The intestines of these animals contain a ferment,
capable of converting amygdaline into prussic acid. 6. Amygdaline injected
into the veins, or into the intestines, passes off in large quantities, sometimes
rapidly by the urine; some experimenters, as Wohler and Frerichs, have not
found amygdaline with certainty in this excretion ; others, as Ranke, suppose
it to be converted into formic acid. — B. and F. Med.-Chirnrg. Rev., April, 1857,
from Allgem. Medicin. Central Zeitung, 1856, p. 72.

MISCELLANEOUS.

66. Ophthalmological Congress. — The Committee of Editors of the li Annates
d' Oculistique" have convoked, at Brussels, a Congress of Ophthalmologists, to
which they invite all members of the profession, in every country, who are
interested in this branch of medical science. The meeting is to be held on the
13th, 14th, 15th and 16th of next September.

The Committee for the organization of the Congress are : —

Fallot, President of the Roy. Acad. Med. of Belgium — President.

Bosch, Surgeon to the Ophthalmological Institute of Brabant, &c. ; Hairion,
Director of the Ophthalmological Institution of the army at Louvain, &c. ; and
Van-Roosbroeck, Director of the Ophthalmological Institute of Brabant, &c. —
Members.

Warlomont, Chief Editor of the Annates d' Oculistique — General Secretary.
All letters and communications relative to the Congress should be addressed
to the Secretary General, Rue Notre-Dame 27, Brussels.
Communications will be received in all languages.

1857.] 283

AMERICAN INTELLIGENCE.

ORIGINAL COMMUNICATIONS.

Note of the Delivery of a Female, one of whose Lower Limbs had been
Disarticulated at the Hip- Joint, seventeen years since, for Morbus Coxarius.
By John H. Packard, M.D. — A few months since, a case of pregnancy
came under my notice, occurring in a coloured girl about 23 years of age.
She seemed stout and hearty, although presenting marks of scrofulous en-
largement of the cervical glands.

1 learned that she had been, in 1840, the subject of disarticulation of the
hip-joint for morbus coxarius. The operation, which was performed by
Dr. Duffy, of this city, was at the time considered a very rash one; the
patient's condition was very low. and the acetabulum was involved in the
disease ; yet the patient, seventeen years afterwards, presents a fine healthy
stump, and a beautiful cicatrix. Her delivery, which took place at the
Blockley Almshouse, was perfectly successful.

Surely this operation, in this case, has "stood the test of time."

No one would pretend to say that this single instance, in which a favourable
result ensued, should lead to the general adoption of this plan of treatment
for coxalgia ; or that the disease was entirely cured in this individual ; but it
might, perhaps, justify a similar operation in some cases, and is, at any rate,
another remarkable instance of recovery under what would be generally con-
sidered desperate circumstances. Perhaps, also, in reference to a case like
this, it might be asked of those who call the necessity for operative interference
the opprobrium of surgery, whether more could be expected of any medical
treatment than to give a dying child an additional term of life of at least
seventeen years ?

Case of Fracture of the Pelvis during Pregnancy. By J. Whitaker,
M. D., of Lewistown, Niagara Co., N. Y. — On the 18th day of December
last, I was consulted by Mrs. "VV., who informed me that she had received a
fall the day before, slipping down a pair of steps, and striking astride the
edge of an open upright barrel. My fears for her safety were aroused when
she informed me that she was in the seventh month of gestation. She com-
plained of excruciating pain in the left pubic region on the least motion. Qn
examination, I found an oblique fracture of the body of the left os pubis ;
there was but little displacement, no lesion of the bladder or rectum, and for-
tunately no positive attempt at miscarriage. A roller bandage was applied
around the pelvis, opiates were administered, and the urine drawn off for
three days by means of the catheter. No bad symptoms supervened, and
in six weeks the patient was able to walk about the room. On the 6th of
March inst. she was delivered, after an easy labour, of a healthy female
child, weighing ten pounds. The fracture was of course reopened, and I
was not surprised in seeing symptoms of peritonitis present themselves;
these were promptly met by bloodlettings, and the exhibition afterward of
calomel and opium. The inflammation yielded kindly, and I am happy to

28 i American Intelligence. [July

state that at this date the patient is doing exceedingly well, and will be up in
a few days.

Ovariotomy Successful. By E. P. Bennett, M. D., Danbury, Conn. —
The patient was a Mrs. Stevens, aged 49, married, and had borne children.
Until within the last six or seven years she had enjoyed good health. I saw
her about the middle of April last, when she appeared almost as large as a
woman at the full period of gestation. Upon examination there was a feel
as of two distinct tumors, but, upon close investigation, I was convinced it was
a case of multilocular ovarian dropsy. The mass was quite movable, so that
I was well satisfied that no extensive adhesions existed. I operated on the
25th of April by an incision about four inches in length; tapped four cysts as
the sac was pulled out by my son ; turned the patient upon her face near the
edge of the table to facilitate the escape of the fluid ; drew out the sac, and tied
with a double ligature. The only trouble experienced in the operation was
the protrusion of the omentum. On the tenth day the ligatures unexpectedly
came away, and at the end of two weeks she was able to sit up and walk
about her room, the wound having entirely closed. This has most truly been
a fortunate case, and I am more firmly than ever grounded in the belief, that
in well selected cases extirpation is of all others the remedy to be relied upon
for the cure of this fatal disease. There are, on the other hand, cases which
cannot be removed with any rational prospect of success in consequence of
extensive adhesions; these are the cases to be treated by injections or by
the establishment of fistulous openings (not into the cavity of the abdo-
men, as recommended by Dr. Simpson, but through the abdominal walls ex-
ternally). Treated in this way the sac continually shrinks, and in some cases
comes away piece by piece, and the patient recovers in a great measure, if not
entirely, her health. The young lady upon whom I operated in Jan. 1856,
continues in good health.

Death following the Inhalation of a Mixture of Ether and Chloroform.
By B, Crockett, M. D., of Wytheville, Va. (Communicated in a letter to
the Editor.) My Dear Sir : I feel impelled from a sense of professional
duty to communicate to you the following case of death resulting from the
use of ether and chloroform.

A sprightly little boy, five years of age, the son of Mr. Bonham, of Smyth
County, was brought to me by his physician, Dr. A. Kincannon, of that
county, to have a fatty tumour removed from his back. The tumour was a
large one, commencing at a point at its inferior termination opposite the last
rib, about two and a half inches to the right of the spinous processes, and
extending obliquely upwards, crossing the spine seven inches, requiring two
elliptical incisions nine inches long for its removal.

The operation was commenced at half-past 9 o'clock A. M., April 4; the
anaesthetic used was a mixture of washed ether, four parts, and one of chlo-
roform. The anaesthetics were procured from Mr. Frederick Brown, whose cha-
racter is a sufficient guarantee that they were pure. Dr. Kincannon, my son
Dr. Joseph Crockett, and an intelligent pupil of mine, Mr. Campbell, present.

The anaesthetic was carefully mixed by myself, and a drachm of it poured
on a funnel-shaped sponge prepared for that purpose. Every preparation for
the operation having been made, the administration of the anaesthetic was
commenced by myself, observing all the precautions so fully recommended by
Erichsen, page 78 of his Operative Surgery, by Brinton. As soon as
anaesthesia was induced, the sponge was confided to Dr. Kincannon, who held
his fingers all the while on the patient's pulse. The operation was com-

1857.]

Original Communications.

285

menced as soon as the patient was brought under the influence of the
anaesthetic; the dissection was rapidly executed, stopping to ligate a large
artery that was early divided; the remaining arteries were compressed by
Mr. Campbell as they were divided; the tumour was quickly removed, and
a ligature applied to the last artery, being the sixth in number requiring
the ligature. Whilst my son was sponging the wound, and waiting to see
if any more arteries would spring, the little boy began to vomit. 1 imme-
diately turned and took hold of his arm, and feeling his wrist, remarked to
Dr. K. that he was pulseless ; Dr. K. replied that " his pulse had never
given way until he began to vomit/' He ejected a small portion of
the contents of the stomach. He was immediately placed in the " prone
position" recommended by Dr. Marshall Hall in the July number of the
American Journal of the Medical Sciences, page 224. I also introduced my
finger into the mouth to be certain that the tongue had not fallen back so as
to obstruct the glottis or the entrance of air into the windpipe. We perse-
vered in these efforts, so fully and ably recommended by Dr. Hall, and my
assistants in the mean time rubbed the extremities with aqua ammonia, &c.
Electro-magnetism was not resorted to, as we were three miles in the country,
and I had not my .electro-magnetic apparatus with me. The patient died in
three or four minutes from the commencement of vomiting. He lost probably
four ounces of blood ; certainly not exceeding six.

When Mr. Campbell removed his fingers from the last artery to be tied,
there was a fine jet of florid blood from it, showing conclusively that he was
not asphyxiated at that time. Anaesthesia was not carried so far at any stage
of the operation as to produce the slightest stertor in breathing. Dr. K.
assured me that up to the time he began to vomit there was nothing in the
circulation or respiration to produce the least apprehension.

A post-mortem examination was prevented by the removal of the body in
the afternoon train of that day.

I have latterly employed this anaesthetic freely, formerly having used ether
alone. As yet I have not seen a case of death reported from ether, or this
mixture of it with chloroform, that I can now recollect. Are then any such
reported ?

I greatly fear all the deaths from anaesthetics are not, reported.

Mental Influence of Mother on Fcetus in JJiero exerted through tvjo successive
Pregnancies. By S. L. Kerr, M. D., of El Paso, Woodford County, 111. —
In the forepart of May, 1852, a little daughter of Mrs. H. fell from a table,
face foremost, on to a cooking-stove sufficiently hot to burn slightly. The
cries of the child quickly brought to her assistance Mrs. H., who was in an
adjoining room. Upon seeing her child on the stove, which she presumed to
be quite hot, she became instantly alarmed, fearing the child was fatally
burned. Her nervous system was shocked to such a degree that she did not
recover from it for two weeks — her mind frequently turning to the accident.
The child was slightly burned on its face, hands, and arms. Mrs. H. was in
the seventh month of her third pregnancy. On July 27 her accouchement
took place ; I was called in ; child was born some time before I arrived.
Mrs. H. was comfortable. Her mother presented the child to me, saying,
"Doctor, it is strangely marked." I was much surprised to see it blistered
on its lips, in mouth, on right ear, on right elbow, both hands and fingers, on
each knee, and on both ankles and feet. The blisters had every appearance
of those from burns, were inflamed at the base, and filled with a light straw-
coloured serum. The child seemed to suffer much pain, and died on the third
No. LXVIL— July 1857. 19

286

American Intelligence.

[July

day. Mrs. H. is of nervous temperament, and, except an attack of chill
fever in April previous, which had continued four or five days, had for some
years enjoyed good health, and was altogether free from disease at that time.

She became pregnant again; accouchement took place Sept. 5, 1853; I
attended her; her labour was short and easy. When the child was brought
to view we were struck with amazement to see it marked precisely on the
same parts and in the same manner as the above described one. The blisters
were full of serum, and had the same appearance in every respect. Inflam-
mation on its hands and feet was deep ; sloughing set in; nearly all its fingers
and toes sloughed off. Blisters on the other parts soon healed. Treatment —
stimulating lotions, and magnesia internally. In October following, ulcers
were all healed, and child healthy. Mrs. H/s health during this last preg-
nancy was good, and her mind was easy. She never once feared that that
child would be marked. In the fall of 1854 she gave birth to another child,
which was healthy and free from any mark. I have seen accounts of several
remarkable cases of the mental influence of the mother upon the child in utero,
but never of a case where the influence extended to the second child. She
feared the first one would be marked ; she had no apprehension that the second
would. The nervous impression must have continued until the second was
affected as above described. Cases less remarkable than the foregoing are on
record; these too, I think, are worthy of a place. I leave them to you and
others for comment.

Case of Arrest of Development. By S. L. Kerr, M. D., of El Paso,
Woodford Co., 111. — Mrs. M., on the 6th April, gave birth to a female child
which has no arm on its right shoulder ; instead of which there is a fold of
skin an inch in length. The arm on the left shoulder is without elbow-joint,
the third and fourth fingers, and that part of the hand behind them. The
distance from shoulder-joint to wrist-joint was precisely four inches. It is free
from any other visible imperfection; it is Mrs. M/a fourth child; other three
are living, and perfect in form. No cause for the freak is known.

Case of Fibrinous Plugs in the Abdominal Aorta, Right Iliac, and Right
Subclavian Arteries. By G. A. Wilbur, M. D., of Skowhegan, Me. — Mr.
J. B., of Norridgewock, Me., aged about 60, a farmer, and rough carpenter,
accustomed to lift heavy weights; while away from home at a hard day's
work, and without dinner, fourteen years since, was taken with severe pain
which he called " cramp" in the stomach, attacks of which he has had, at
irregular intervals, ever since. When a paroxysm commenced, it could usually
be stopped by swallowing food, or a carminative; and when it left him it was
with a gurgling sensation, as if the cause had been gas.

Dec. 28, 1856. After having suffered for about a week with an unusual
headache and slight chills on retiring, he was seized with excruciating pain in
the right leg, with a violent chill that chattered his teeth and shook his bed.
Stimulants and rubbing were applied to the leg, and in a few hours the pain
subsided. In three or four days the pain seized his right forearm, which also
yielded after six or eight hours, leaving the arm palsied for a time, and per-
manently pulseless. In each instance the chill was followed by a hot stage,
which was succeeded by a profuse sweat. These paroxysms, excepting the
pain, continued to occur at irregular intervals of about twenty four hours.
During three or four of the paroxysms he was noticed to be slightly delirious;
at other times he was rational and calm. He slept well, unless under the
influence of an opiate, which, as heretofore, made him wakeful.

1857.]

Domestic Summary.

287

Jan. 10, 1857. I was called for the first time to see him, when I obtained
the above history of the case from his family. I found him with left eye
somewhat suffused, articulation rather indistinct, and deglutition clumsy;
right wrist, elbow, axilla, and subclavian pulseless; sought for tumour in sub-
clavian region, but found none; therefore examined right leg, no pulse at the
ankle, and only a slight jar at the knee. Although the pulse was absent at
the right wrist, yet, on compressing the artery, I could at the moment perceive
the blood flow against my finger as if obstructed by it. This pulseless condi-
tion continued until death, excepting, when the arm had been rubbed for half
an hour, I could detect a slight pulse at the wrist. He continued to have
the shakes, hot and sweating stages at irregular intervals up to the 13th,
when he had a violent paroxysm in the evening as his shake passed off. I
found him with a pulse so irregular as to prevent counting it; the action of
the heart also irregular and furious, both sounds resembling that elicited by
snapping the finger against a piece of thick cloth very moderately stretched.
The pulsation of the abdominal aorta in the hypogastric region sounded like
percussion over a tympanitic abdomen, and was audible at the distance of
eight or ten feet at least; these sounds arose above those of the heart, even
with the ear applied to the cardiac region for the purpose of auscultation.
He had no more shakes, but in their stead he had paroxysms of similar action
of heart and aorta up to the morning of the 17th, and the only change in his
symptoms was a gradual loss of strength. On the morning of the 17th he
suffered considerably from pain in the right limbs, and, for the first time since
his attack of chills, from his old acquaintance " cramp in the stomach." On
the evening of this day he was very low, pulse irregular and weak, and the
dorsum of right foot and parts of the leg had assumed a dark mahogany
colour, not to be scattered by friction or pressure; this discoloration gra-
dually spread over his right leg, arm, back, and left leg, and he sunk gradually
until the 23d, when he died.

Post-mortem examination had about thirty-six hours after death. — We de-
tected no disease of the stomach, liver, bowels, kidneys, pancreas, or lungs,
excepting a slight congestion of left lung. Spleen weighed about two
pounds, and was so softened in places as hardly to retain its form when laid
upon a level surface. Heart: the inner surface of the left auriculo-ventricular
opening presented a spot about three-quarters of an inch in length by one-
sixteenth of an inch wide, of a dark brown colour, and indurated like a scir-
rhus. The discoloration is not entirely lost, though macerated in alcohol for
more than two weeks. Arteries : the subclavian where it gives off the thy-
roid axis, the abdominal aorta at its bifurcation, and the right common iliac
at its bifurcation, were plugged with what seemed to be fibrin almost organized.
How did the disease of the heart, or other cause, produce these plugs ?

DOMESTIC SUMMARY.

Excision of the Tonsils. — Dr. J. Mason Warren made (March 23d, 1857) a
highly interesting communication to the Boston Society for Medical Improve-
ment on this subject.

He stated that he had lately removed the tonsils from a child in whom, in
addition to the ordinary symptoms of obstruction to the breathing and altera-
tion of the voice, was produced a most remarkable spasmodic cough, resembling
the barking of a dog.

288

American Intelligence.

[July

Dr. W. said he would take this opportunity to speak of the result of his
experience in the operation for excision of the tonsils. Some years since (1839)
he had read, before this Society, some remarks on enlargement of the tonsils,
attended by certain deformities of the chest, and the result of twenty cases
was given, in which the operation had been performed. This was published
afterwards in the Philadelphia Medical Examiner. More lately, he had given
the result of two hundred cases which required operation ; and at present, his
experience would reach to above five hundred instances in which the tonsils
required to be removed. These cases had not been taken indiscriminately, but
the operation was only performed where the symptoms were more or less urgent,
and other remedies had failed in affording relief: causing deformity of the
chest, difficulty of breathing, choking at night, unnatural and offensive dis-
charge from the mouth and nasal passages. Many of these cases were brought
from a distance, on account of the importance and severity of the disease.

In none of these cases had he ever seen any fatal accident occur, or had
reason to regret the operation. In but two cases, and those not in his own
practice, but where he had been called in after the operation, had he seen any
serious hemorrhage; both these cases did well. In almost all of them the
symptoms were at once relieved ; the patient was able to take his food with
comfort, to sleep better, and exchanged a pallid and depressed aspect, for a
healthy and animated appearance. To the rapidity with which some of them
had gained flesh, as soon as a proper amount of oxygen was allowed to pene-
trate to the lungs, many of the gentlemen present would bear witness. He
could conscientiously say that he knew no minor operation in surgery that
afforded greater relief and more satisfactory results than the one under con-
sideration.

In answer to the question whether the tonsils were ever reproduced, requir-
ing a repetition of the operation, Dr. W. said that in four or five instances only
had he been obliged to repeat the operation. The whole of the tonsil never is,
or ought not to be, removed. "When the enlargement is very great and irreg-
ular, it sometimes extends down the throat with a broad base, and it is not
possible to embrace at once in the instrument as much of the tonsil as it would
be desirable to remove, and the apex only is excised. The consequence is, that
the lower portion afterward rises up and comes into view, causing obstruction,
and requiring another operation. These cases, were, however, very exceptional.

The instrument that Dr. Warren had always used was the guillotine instru-
ment, introduced into practice by Dr. J. C. Warren, made perfectly simple,
without any needle or spring, to seize or drag out the part to be removed. The
thick mucus of the fauces causes the portion cut off to stick to the instrument,
so that it seldom escapes into the throat. The objection to those instruments
which cut by pulling the knife out, is that they require to be kept constantly
sharp, otherwise the tonsil may be dragged or torn. The guillotine instrument
does not require this ; in fact it is better dull, causing less hemorrhage, and
possibly a subsequent greater destruction of that part which remains. His
own instrument had been at the instrument-makers but once or twice for the
last fifteen years. It was kept bright and in good order by not putting the
blades together except when used.

In this connection, Dr. W. said that he had once seen death occur from
enlargement of the tonsils. A young man was brought into the Massachusetts
General Hospital in a state of strangulation, and it was necessary to open the
trachea to save him from instant death. Stimulating injections of brandy and
water were given him, as he was unable to swallow, and by this means he was
kept alive some hours, but finally died from exhaustion. It was subsequently
ascertained that he had been confined some days on board ship with a sore
throat, but no danger had been apprehended until the urgent symptoms came
on for which he was rer.oved to the hospital. After his death, the finger being
introduced into the throat, revealed the cause of his death. The tonsils were
so much enlarged as to completely fill up the posterior fauces, and were firmly
wedged one into the other, and had finally pressed down the epiglottis, entirely
obstructing the passage of air to the lungs. (See Society's liecords, vol. i. p.
233.) — Boston Med. and Surg. Journ., April 23, 1857.

1857.]

Domestic Summary.

289

Complete Dislocation of the Cervical Vertebra?. — Dr. Daniel Ayres, of Brook-
lyn, N. Y., records (New York Jour n. of Med., Jan. 1857,) an interesting ease of
this, in which reduction was effected on the tenth day, and the patient re-
covered.

The subject of it was a labouring man, 30 years of age, tall and muscular,
with a neck longer than usual, who, on the evening of the 2d of October, was
taken home drunk and insensible. When he recovered, the next morning, his
sensibility, his wife supposed him to be suffering from a stiff neck and cold,
and made some domestic applications, without relief being afforded.

On the ninth day after the accident, Dr. Ayres was called in to see him,
when his condition was as follows : — •

"With some assistance and great personal effort, he was able to get out of
bed, moving very slowly and cautiously. Desiring to expectorate, he was
obliged to get down on hands and knees, which he accomplished with the same
deliberation. When seated in a chair, the head was thrown back and perma-
nently fixed; the face turned upwards with an anxious expression. The
anterior portion of the neck, bulging forwards, was strongly convex, rendering
the larynx very prominent. The integuments of this region were exceedingly
tense and intolerant of pressure. The posterior portion of the neck exhibited
a sharp, sudden angle at the junction of the fifth and sixth cervical vertebrae,
around which the integuments laid in folds. It was difficult to reach the bot-
tom of this angle even with strong pressure of the fingers, and of course the
regular line formed by the projecting spinous processes was abruptly lost. He
complained of intense and constant pain at this point, which was neither
relieved nor aggravated by pressure. With difficulty he swallowed small
quantities of liquid, pausing after each effort, and could not be induced to take
solid food, since the first attempt to do so after the accident was followed by
violent paroxysms of coughing and choking. His breathing was obstructed
and somewhat laboured, being unable fully to clear the bronchia of their secre-
tion. This, however, seemed rather an effect of the tense condition of the soft
parts of the neck, than the result of pressure upon the spinal cord, since he
presented no evidence of paralysis, either of motion or sensation, in parts below
the neck. The sterno-cleido-mastoid muscles of both sides were felt quite soft
and relaxed.

" But one conclusion could be formed upon this state of facts, to wit: that the
oblique processes of both sides were completely dislocated. The marked
rigidity of the head seemed to preclude the probability of fracture through the
vertebral bodies, and although the cartilage might be separated anteriorly, yet,
the body not pressing backwards sufficiently to produce paralysis of the cord,
it was hoped that the posterior vertebral ligament remained uninjured; it was,
therefore, determined to make an effort at reduction on the following day.

" The patient was placed upon a strong table in a recumbent position, with
a pillow resting under the shoulders, the head being supported by the hand
during the administration of chloroform, of which an ounce was given before
ansesthesia ensued. Counter extension being made by two folded sheets placed
obliquely across the shoulders and properly held, the head was grasped by one
hand placed under the chin, the other over the occiput, and by steadily and
firmly drawing the head directly backwards, and then upwards, an attempt
was made at reduction, but failed for want of sufficient power. Dr. Ingraham
was then requested to place his hands immediately over my own in the same
position as before, and steady traction was again made in the same direction.
Our united strength was required in drawing the head backwards and upwards,
to dislodge the superior oblique processes from their abnormal position. When
this was felt to be yielding by Dr. Cullen (who kept one hand constantly at
the seat of dislocation), Dr. Potter was directed to place his hands under our
own, still in position, and assist in bringing the head forward ; at the same
time the chest was depressed towards the table. The bones were distinctly
felt to slip into their places ; the line of the spine was instantly restored, the
head and neck assuming their natural position and aspect. As soon as the
patient became conscious, he expressed himself ignorant of what had taken
place, but free from pain, and, in his own language, ' all right.' A bandage was

290

American Intelligence.

[July

arranged to support the head and keep it bent forward. He had an anodyne
for two nights following, after which no further treatment was necessary, and
at the end of one week he had complete control over the movements of the head
and neck. Beyond the debility and emaciation immediately dependent upon
protracted fasting and loss of rest, he has experienced no uneasiness since the
operation. His appetite is now good, and all the functions perform their duty
normally. In a subsequent inquiry, to determine if possible the cause of the
accident, he states that he distinctly recollects going into a store in Atlantic
Street, near the ferry, and there having angry words with an acquaintance ;
that he left the store and was proceeding up the street (which is here a rather
steep ascent), when he was violently struck from behind, over the lower por-
tion of the neck. He likewise remembers falling forward and striking against
some object, but does not know what it was, nor what took place until the fol-
lowing morning."

Femoral Aneurism cured by Veratrum Viride, Manipulation and Compression.
— In our number for January last, p. 256, we noticed the proposition of Mr.
Fergusson to treat aneurisms by manipulation, and in our present number, p.
244, we have given the details of a case of subclavian aneurism successfully
treated by this means by Mr. Little.

Dr. Geo. C. Blackman, Professor of Surgery in the Medical College of Ohio,
reports {Western Lancet, June, 1857) the following interesting case of femoral
aneurism treated by this plan combined with pressure and the administration
of veratrum viride: —

"John Austin, get. 28, a native of England, entered the Commercial Hospital
on the 7th of April. Four months previously, he felt a sharp pain along the
course of the femoral artery at the junction of the lower and middle third of the
thigh, and for the first time he observed a pulsation in this region. He had
worked for many years as a file-cutter, and had been accustomed to use a small
anvil, which was held between his thighs. A swelling was soon detected, and
this continued to increase until the time of his admission. There was a space
of about three inches between the upper margin of the tumour and Poupart's
ligament, and measured along the axis of the limb, the swelling was five inches
at its base. The aneurismal bruit was very distinct, and the pulsations percep-
tible across the amphitheatre. Compression at the groin caused the tumour to
diminish considerably in size, and it would immediately regain its former
dimensions when the pressure was removed. The patient complained of numb-
ness and other painful sensations in the knee, leg, and foot. As the tumour was
daily increasing, and as there was no other indication of disease of the arterial
system, I determined to bring the patient under the influence of veratrum
viride, in order to subdue the force of the circulation. From the time of his
admission he was kept on a low diet, and cathartics were administered. On
the 11th, I ordered six drops of the tincture every three hours. On the morn-
ing of the 12th, I found that the pulse had been reduced in frequency from 94
to 65. At ten o'clock A. M., of this day, he was brought before the class, when
with my thumb I pressed forcibly into the aneurismal sac, for the purpose of
dislodging a portion of its fibrinous layers, hoping thus partially to obstruct
the artery, and to favour the further deposition of fibrin in the sac. Skey's
tourniquet was now applied with moderate force between the tumour and Pou-
part's ligament. The progress of the case may be learned from the following
record, kept by Dr. N. J. Sawyier, the House Surgeon : —

" At 12 A. M., his pulse being 110, full, strong, and bounding, he was bled
Jix. Pulse came down to 50, soft and regular, and continued low for several
days. (The following are extracts from the Case-Book): —

"April 13, A. M. Suffers no pain nor uneasiness at all ; slept well last night.
Entire limb diminishing rapidly in size. Kept the apparatus tight. General
health good; whenever any untoward symptom arose, it was promptly met, and
the patient kept in a good condition. At intervals, the shooting pain was felt
in the tumour, but it gradually subsided altogether.

" 17th. Prof. Blackman ordered the tourniquet to be taken off, the bandage
reapplied from the toes, up over the tumour, upon which it was to be tightly

1857.]

Domestic Summary.

291

wrapped, and the patient to be bled, after which the following was adminis-
tered: R. — Antimon. and potass, tart. gr. \ ; pulv. opii gr. Sig. — Take
every 3 hours. Patient's pulse came down to 65, soft and regular.

19th. Souffle ceased entirely, but the pulsation continues, though it is very
weak.

" 22d. Pulsation in tumour has ceased altogether.

"25th. Is in fine spirits; has no pain, and wants to walk about. General
health very good.

"30th. Has walked some steps, and complains of nothing but weakness.

" May 21. The pulsation in the tumor has never returned. The femoral is
firmly plugged as far as the origin of the profunda, and in the popliteal space
the pulsation of the artery is hardly perceptible. The tumour is daily decreas-
ing in size, and the patient is anxious to leave the hospital and resume his
business."

Paracentesis Thoracis. — In the number of this journal for April, 1852, will
be found an interesting paper on this subject, by Dr. Henry J. Bowditch, of
Boston.

In a more recent paper {Bost. Med. and Surg. Journ., June 4, 1857), Dr. B.
states that his subsequent experience has confirmed his belief of " the import-
ance of this operation as a remedial measure, to be used not as a last resource,
but like any other simple remedy, if necessary, at any period of the disease.
I still use the exploring trocar, although, in some instances, where there has
been a tendency to a re-accumulation of fluid, I have used a larger instru-
ment."

He further states, that "since April 17, 1850, I have operated upon sixty-two
individuals, of both sexes and all ages. I have punctured one hundred and
eleven times. I know of nothing in practical medicine which has afforded rne
more satisfaction than this simple operation. I use designedly the expression
— practical medicine, in contra-distinction to surgery. The perfect simplicity
of the operation, to one satisfied of the correctness of his diagnosis, allies it to
venesection or vaccination. I am well aware that many will wonder, and some,
perhaps, will scoff at this classification. To such I would say — Do not theorize
on your fears — try the operation, and then you can judge more clearly. You
will find that, as performed in these cases (viz., with the exploring trocar), it
is, 1st, as a general rule, less painful than a blister ; 2d, that (if I may judge
from my cases) it never does harm; 3d, when fluid is obtained, it always gives
relief, either temporary or permanent; 4th, that very often it is the chief, if
not the sole means capable of relieving severe symptoms, and even of saving
life.

"If these statements are true — and I am as convinced of their truth as 1 am
of anything in my whole medical experience — I am justified in asserting, that
a physician does wrong and acts foolishly who allows any patient to suffer
months or years of misery, or even death itself, from pleuritic effusion, at any
age, from any cause and with any complications, without, at least, a trial of
thoracentesis. I write thus strongly because I fear that surgeons, of even the
highest reputation, still snrink from performing this operation. This fear, I
presume, is owing to their considering it as similar to the operation laid down
in all, or almost all, of their own manuals. From that operation they ought in
most cases to shrink. That which is here advocated is of a totally different
character, and is, so far as my experience goes, harmless."

Chalk and Vinegar in Intermittent Fever. — Dr. Hodsden stated, at the recent
meeting of the East Tennessee Medical Society, that he had been eminently
successful in this treatment of intermittent fever with a mixture of prepared
chalk and vinegar. Every case had been cured, and without relapse. The
dose is a tablespoonful of each, mixed together, and allowed to stand, to allow
effervescence to take place, and then given an hour before the expected time of
the chill. It acts always freely on the bowels and kidneys. A friend in the
West, from whom he learned this remedy, stated that he had seen hundreds
cured by it. — Nashville Journ. Med. and Surg., June, 1857.

292

American Intelligence.

[July 1857.]

Gunshot Wound of the Heart and Stomach. — Dr. J. H. Grant reports ( Charles-
ton Med. Journ., May, 1857) a remarkable case of this. The subject of it, a con-
stable, received a ball from a revolver which entered " a little to the right of
the sternum, between the cartilages of the fifth and sixth ribs," perforated the
pericardium, " entered the right ventricle about an inch from the apex, and
emerged from the same on the under side of the heart, before going far
enough to enter any other cavity," passed through the diaphragm and through
the cardiac extremity of the stomach, and lodged on the left kidney. This man
was in a state of collapse for fifteen hours, and continued to live for twenty-six
days, without taking any nourishment. When the post-mortem was made, the
wounds in the organs had healed, but the cicatrices were evident.

Dislocation of the Femur reduced by Reid's Method. — Dr. T. G. McElbright
records ( Western Lancet, April, 1857) a case of this. The subject of it was a
lad 7 years of age, who had dislocated his femur on the dorsum of the ilium by
a fall. The patient was rendered insensible by the inhalation of equal parts of
chloroform and sulphuric ether, and in thirty seconds the dislocation was
reduced.

Wutzer's Operation for the Radical Reduction of Hernia. — This operation was
successfully performed on the 9th of March last on a patient, in the Commercial
Hospital, by Prof. Geo. C. Blackman. The instrument was kept applied for six
days, with but little suffering to the patient, and Dr. B. satisfied himself three
weeks after the operation that the canal was completely closed. — Western Lancet,
April, 1857.

Spina Bifida, with Malformation of the Genitals. — In a paper published in the
number of the Journal for October, 1856, Dr. Wm. H. Byford called attention
to the concurrence of spina bifida and malformation of the genitals, and related
three cases in which these coexisted.

Dr. S. Kneeland, Jr., of Boston, relates [Boston Med. and Surg. Journ., Feb.
12, 1857) a case in which these malformations coexisted. There were five
spinal tumours over the last lumbar vertebrae.

Below the pubic region there was a protuberance, about one-third of an inch
in prominence, and the same in diameter, looking more like an inversion of the
mucous surface of the bladder than a penis — from this the urine constantly
dribbled. There did not seem to be any bone where the pubis ought to be,
and the finger could be pressed down quite deeply above the " penoid" protu-
berance into a yielding mass of viscera, which, from the gurgling of air and
fluid, were evidently folds of intestine ; whether these descended into the
structure next described, forming a hernia, could not be clearly made out.
On each side of the penis was a scrotum, extending round under the perineum
to within half an inch of the anus ; I call this a scrotum (though I could detect
no testis in it) from the perfect resemblance of its wrinkled skin to that organ.
This scrotum was about an inch wide and high in its middle portion, whence
it faded out gradually towards the penis and anus; it looked very much like
the old-fashioned epaulette of the common soldier. Between these scrotums,
or " scrota," was a fissure extending for their whole length, which could be
opened for about half an inch in its deepest part; it presented the ordinary
appearance of the genital mucous membrane. No opening could be seen in it.

Treatment of Erysipelas with Tobacco. — Dr. J. G. Stephenson calls ( Western
Lancet, May, 1857) the attention of the profession to the treatment of erysipelas
by tobacco, and asserts that this agent is the most reliable one for subduing
erysipelatous inflammation of which he has any knowledge. He covers the
inflamed surface with wat tobacco leaves, which he permits to remain until
much nausea is produced.

That the tobacco is as safe an application as the nitrate of silver can, we con-
ceive, scarcely be maintained ; while a more effectual application than the
latter can hardly be required.

American Journal of Med. Sciences.

293

GRADUATES OF THE UNIVERSITY OF PENNSYLVANIA, 1857.

At a Public Commencement, held March 28, 1857, in the Musical Fund Hall, the Degree
of Doctor of Medicine was conferred by Henry Vethake, LL. D., Provost, upon the
following gentlemen ; after which an Address was delivered by Samuel Jackson, M. D.,
Professor of the Institutes of Medicine.

NAME.

Avery, "Wm. C.
Barnet, Gabinus J.

TOWN or p. o.
Greenborough,

Havana,

Biegler, Jos.
Blackwell, Lewis S.
Boaz, Crispin D. (M.D.)
Bondurant, Thos. L.
Boude, John K.
Bowers, Lorenzo F.
Bowman, David Good
Bowling, James Butler
Boykin, Edwin D.
Bradley, Ely
Bragg, John C.
Breed, S. P. (M. D.)
Bynum, Jos. M.

Bynum, Mark W.

Caldwell, Henry M.
Carter. John L.
Carter, Wm. E.
Caruthers, John W.

Rochester,
Pennington,
New Concord,
Buckingham C.
Carthage,
Mt. Carmel,
Philadelphia,
(M. D.)
Cooksville,
Belleville,
Petersburg,
Pleasant View,
Pittsborough,

Tripoli,

Greenville,
Scoober,
Lumpkin,
Commerce,

COUNTY.

Green,

Monroe,
Mercer,
Calloway,
H.

Hancock,
Wabash,

Noxubee,

Conecuh,

Dinwiddie,

Schuyler,

Chatham,

STATE. SUBJECT OF THESIS

Ala. The Physician.

Cuba.

N. Y.

X.J.

Ky.

Ya.

111.

Pa.

Ky.

Miss.

Ala.

Ya.

111.

1ST. C.

Catchings, Thos. A.
Cecil, Thcs. W. (M. D.
Chandler, A. Henry
Chanev, Thomas Y.
Chappell, 0. W.
Child, Duff D.
Coleman, Warner W.
Colley, Francis S. (M.
Cooper, John
Coppedge, Oliver D.

Coriell, W. Wallace
C ottilla, Edw. F.
Cousins, A. S.
Crichlow, John
Curry, Walker
Cutter, Benj. (M. D.)

Bolton's Depot.
) Cedar Bluff,
Dorchester,
Deer Creek,
Dinwiddie C.H.,
Mobile,

Gloucester C.H.
D.) Monroe,
Cooper's Plains,
Cedar-Rock,

Rahway,

Havana,

Petersburg,

Williamston,

Kelly's Springs,

Woburn,

Tishomingo, Miss.

Butler, Ala.

Kemper, Miss.

Stewart, Ga.

Tunica, Miss.

Hinds, Miss.
Tazewell, Ya.
Westmoreland, N. B.
Issaquena, Miss.

Ya.
Ala.
Ya.
Ga.
N. Y.
N. C.

Mobile,
Gloucester,
Walton,
Steuben,
Franklin,

Essex,

Cuba,

Dinwiddie,

Martin,

Talladega,

Middlesex,

N. J.

Cuba.
Ya.
N. C.
Ala.
Mass.

Cutter, Ephraim (M. D.) Woburn,

Middlesex, Mass.

Davis, Robert M.
Dayton, Ferdinand Y.

Demme, Theodore A.
Dimmitt, Elijah C.

Dixon, Jos. E.
Dorsey, Harry W.
Duer, James H.

Xew Store,
Trenton,

Philadelphia,
Germantown,

Columbia,
Frederick,
Cincinnati,

Buckingham,
Mercer,

Mason,

Maury,

Frederick,

Hamilton,

Ya.
N. J.

Pa.
Ky.

Iodide of Starch as a substi-
tute for Cod-liver Oil in the
Treatment of Phthisis Pul-
monalis.

The Laws of Health.

Papaver Somniferum.

Enteric Fever.

Phthisis Pulmonalis.

Delirium Tremens.

Irritable Uterus.

Erysipelas.

Variola.
Dentition.
Anaesthesia.
Sympathy.

Cinchona : its Alkaloids, and

their Substitutes.
Epidemic Cholera.

Enteric or Typhoid Fever.

Anaesthesia.

The Tongue in Disease.

Emetics, and their Mode of

Action.
Wounds of the Abdomen.
Polypus of the Uterus.
Mania.
Pneumonia.
Dysentery.

Function of the Spleen.
Cholera Infantum.
Enteric Fever.
Hydrated Sulphuric Acid.
Anatomy and Physiology of

the Skin.
Inflammation.
Leprosy.

The Physician's Life.
Variola Confluent.
Hypertrophy of the Heart.
False Cartilage in the Knee-

Joint.
Endosmosis.

Cholera Infantum.

The Effects of Solar Light on

Animal Life.
Metastatic Abscesses.
The Early Treatment of

Children.
Tenn. Epispastics.
Md. Pleurisy.
Ohio. Correlation
Physical.

Psychical and

294

American Journal of Med. Sciences.

NAME. TOWN OR P. 0. COUNTY.

Estes, Henderson Columbia, Maury,

Everett, Robert C. South Quay, Nansemond,

Everingbam, Joseph West Point, Lee,

Ewing, Henry M. Pulton House, Lancaster,

Fisher, Calvin P. TV. Boalsburg, Centre,

Forbes, Jos. J.
Forwood, J. Larkin.

Fraser, E. Irvin
Friend, Nathaniel
Fuller, John L.

Graves, James T.
Grigsby, Jas. L.

Handy, John H.
Hanner, Jas. P.

Harris, Chas. H.
Hattie, Alex. Gr.
Hawkins, Wm. H.

Henkel, Caspar C.
Hicks, Benj. B.
Hinkle, Albert G. B.
Holmes, Laurentius
Huntington, David L.

Jackson, John D.

James, A. TV.
James, John M.
Jarratt, Jerome S.

Jennings, Clement A.
Johnson, Thos. TV.

Jones, Chas. TV.
Jones, John TV.

Greenville, Pitt,
Chester, Delaware,

Harper's Home, Brunswick,

Eutaw,
Leasburg,

Tanceyville,
"Winchester,

Franklin,
Franklin,

Rolesville,
Caledonia,
Rocky Comfort,

New Market,
Oxford,

Point Pleasant,
Olive Branch,
Charlestown,

Danville,

Hanging Rock,
Vicksburg,
Holly Springs,

Church Hill,
Nassau N. P.,

Dover,
Tarborough,

Greene,
Caswell,

Caswell,

Clark,

Williamson,
Williamson,

Wake,

Guysborougi
Sevier,

Shenandoah,
Granville,
Bucks,
De Soto,
Middlesex,

STATE. SUBJECT OF THESIS.

Tenn. The Human Organism.
Ya. Scarlatina.
Iowa. Conduct of Natural Labor.
Pa. Pneumonia.

Pa.

N. C.
Pa.

Ya.
Ala.
N. C.

Cold : its Importance as a
Therapeutical Ansesthetical
Agent.

Acute Rheumatism.

The Physiology of the Circu-
lation .

Enteric Fever.

Anaesthesia in Labor.

Inguinal Hernia.

N. C. Influences Modifying the Ef-
fects of Medicines.
Ky. Dysentery.

Tenn. Acute Dysentery.

Tenn. Action of Quinia and analo-
gous Alkaloids.

N. C. Diagnosis.
N. Sco. Inflammation.

Ark. Diseases most common to
Southwestern Arkansas.

Ya. Inguinal Hernia.

N. C. Acute Dysentery.

Pa. Enteric Fever.

Miss. Cholera Infantum.

Mass. Quarantine : its Effects and
Necessity.

Boyle,

Lawrence,

Warren,

Marshall,

Ky.

Ohio.
Miss.
Miss.

Halifax, Ya.
Harbor Island, Baha-
mas.

Kent, Del.
Edgecombe, N. C.

Yis Conservatrix et Medica-
trix Naturae.

Miasmatic Remittent Fever.

Habitual Constipation.

Pneumonia modified by Ma-
laria.

Acute Gastritis.

Acute Rheumatism.
Inflammation.
Vasa Capillaria.

Kile, Hiram Irontown, Lawrence, Ohio. Typhus Fever.

Knight, Chas. W. Tarborough, Edgecombe, N. C. Morbus Coxarius.
Kollock, John M. Greenwich, Cumberland, N. J. Euonymns Atropurpura.

Landram, Thos. D.
Le Conte, James
Lesley, Wm. Wood
Little, J. Russell (M.D.) Pembroke,

Longabaugh, N. H.
Losch, Henry

Lowry, Triplett E.
Lyon, Samuel E.

Magee, James I.
Maney, Hardy James
Markley, Artbur D.
Martin, Alfred J.
McCorkle, Alfred L.

(M. D.)
McLeod, Geo. I.
McMahon, F. S. S.
Mellick, Wesley
Merritt, Daniel S.

Mt. Pleasant, Spottsylvania, Ya. Placenta Praevia.
Macon, Bibb, Ga. Inflammation.

Philadelphia, Pa. Remittent Fever.

Merrimac, H.N. Relation of Mind and Body.
NorristoAvn, Montgomery, Pa. Hemorrhage.
Philadelphia, Pa. Etiology considered from a

Philosophical and Psycho-
logical point of view.

Lowry,

Bedford,

Ya.

Menstruation.

Leesburg,

Washington,

Tenn

Scarlatina.

Chester,

Delaware,

Inflammation.

Franklin,

Williamson,

Tenn.

Anatomy of the Eye.

Pboenixville,

Chester,

Pa.

Abortions.

Alltntown,

Lehigh,

Pa.

Cynanche Trachealis.

Lexington,

Rockbridge,

Ya.

Lithuria and Oxaluria.

Wellsboro',

Tioga,

Pa.

Intramural Interments.

Coartland,

Lawrence,

Ala.

Asphyxia.

Light Street,

Columbia,

Pa.

Indigestion.

Philadelphia,

Pa.

The Sense of Yision.

American Journal of Med. Sciences.

295

TOWN OR P. 0.

STATE.

SUBJECT OF THESIS.

Mock, Andrew L.
Monette, Wm. E.
Morgan, Geo. H.
Mott, Alex. B. (M. D.)
Myers, Arthur P.

Nash, Thos. S.
Norcom, Wm. A. B.

Oliver, Wm. A.
Oliver, Wm. J.

Owen, Goronwy

Parker, Rich. E.
Pitts, Aaron B.
Pugh, Thos. C.

Clemmonsville, Davidson, N. C. Colo-rectitis.

Yickshurg, Warren,

Wysox, Bradford,
New York City,

Sumpterville, Sumpter,

Miss. Acute Gastritis.
Pa. Morbus Regius.
N. Y. Hernia.

Ala. Human Family Diversities,
and Causes of those Diver-
sities.

Elizabeth City, Pasquotank, N. C. Irritative Fever.
Edenton, Chowan, N. C. Acute Gastritis.

Dunnsville,
Tallahassee,

Mobile,

Gatesville,
Shop Springs
Williamston,

Essex,
Leon,

Mobile,

Gates,

Newby Dist.
Martin,

Va. Menstruation.

Fla. Diseases of Wakull

Florida.

Ala. Yellow Fever.

N. C. Rubeola.

S. C. Opium.

N. C. Pain.

County,

Redondo, Pedro

Reid, Wm. T.
Reily, Geo. W.

Riddiek, Reuben B.
Robinson, Augustus

Roedel, Henry H.
Rossel, Alfonso A.

Ruin, John K.

Havana,

Crawfordsville,
Harrisburg,

Gatesville,
Annapolis,

Taliaferro,
Dauphin,

Cuba.

Ga.
Pa.

Gates, N. C.

Nova Scotia.

Lebanon, Lebanon,
Flewelling"s X

Roads, De Soto,

Graham, Alamance,

Pa.

Miss.
N. C.

Menstruation a Necessary

Function.
Microscope.

Foeticide, or Criminal Abor-
tion.

Specific Urethritis.

The Physiology and Anatomy

of the Pancreas.
Hysteria.

Acute Gastritis.
Anatomy and Physiology
the Pancreas.

Satterfield, Gustavus A.
Saville, Henry M.
Schell, Henry S.
Schoales, Jos. D.
Seehorn, J. W.
Sheppard, Nicholas C.
Sherk, John L.
Shimer, Jacob S.

Shippen, Edward

Smith, Elliott
Smith, Jos. E.
Smith, Wm. C.

Santa Fe,
South Boston,
Philadelphia,
Philadelphia,
Watauga Bend,
Curdsville,
Lebanon,
Shimersville,

Philadelphia,

Yicksburg,

Pineville,

Averasboro'

Sommerville, James M. Philadelphia,
Stanton, David (M. D.) New Brighton,

Sutphen, P. Theod. Pluckemin,

Maurv,
Suffolk,

Washington,
Buckingham,
Lebanon,
Lehigh,

Warren,

Bucks,

Harnette,

Beaver,
Somerset,

Tenn.

Mass.

Pa.

Tenn.

Va.

Pa,

Pa.

Miss.
Pa.
N. C.

Pa.
Pa.

N. J.

Cholera Infantum.

Idiocy.

Phthisis.

Digestion of the xirnylacea.

Typhoid Fever.

Enteric Fever.

Dropsy after Scarlatina.

Chemical and Therapeutical
Application of Electricity.

Reid s Plan of reducing Lux-
ation of Femur on the Dor-
sum Hii.

Bilious Remittent Fever.

Icterus.

The Effects of the Imagina-
tion in Production and Cure
of Disease.

Cholera Morbus.

Nitras Argenti in Cholera In-
fantum.

Cathartics.

Tatum, Robert F. Oak Park,
Taylor, Rich. H. (M.D.) Memphis
Terry, Henry
Thompson, Sidney
Thompson, Wm. S.
(M. D.)

Madison,
Shelby,

Halifax C.H., Halifax,
Milroy, Mifflin,
Pleasant Grove, Lancaster,

Tryon, John S.

Rehrersburs

Berks,

Va.

Tenn.

Va.

Pa.

Dyspepsia.
Physician's Mission.
Syphilis.

Physician's Mission.

An Abnormal Condition of
the Female Organs of Gene-
ration.

Traumatic Tetanus.

Ky.

Waddy, D. T. (M. D.) Lovelaceville, Ballard,

Wallace, Wm. Fredericksburg, Spottsylvania, Ya

Warne, Jas. H. Nashville, Davidson,

Watkins, Wm. J. Young's X Roads, Granville, N. C

Wharton, Alfred Philadelphia, Pa,

Enteric Fever.
Catamenia.
Tenn. Oxygen Gas.

Enteric Fever.
Inguinal Hernia.

296

American Journal of Med. Sciences.

NAME.

Whyte, Thos. E
Williams, Samuel R.
Wilson, William L.
Winder, Wm. N. J.
Winstead, John H.

Withers, John W.
Wood, Granville B.

town or p. o.
Chapel Hill,
Monticello,
Nashville,
Drummondtown
Joyners,

COUNTY.

Orange,

Jefferson,

Davidson,

Accomack,

Wilson,

Madison Depot, Madison,
Pleasant Grove, Lancaster,

N. C.
Fla.
Tenn
Va.
N. C.

Ala.
Pa.

!. SUBJECT OF THESIS.

Hypochondriasis.
Hypochondriasis.
Laws of Generation.
Tuberculosis.

American Turpentine and its
Oil.

Puerperal Peritonitis.
Urinary Deposits.

Young, Santford C. Garrettsburg, Christian, Ky. Scurvy.

At a public Commencement, held July, 1856, the Degree of Doctor of Medicine was con-
ferred on —

TOWN or p. o.

COUNTY. STATE.

SUBJECT OF THESIS.

Walter G. Garth, Charlottesville, Albemarle, Va. Circulation of the Blood.

Franklin Eads, Hobbie,

John L. Ivey, Weldon,

William M. Scott, Norristown,

Th. George Morton, Philadelphia,

Sumpter, Ala.
Halifax, N. C.
Montgomery, Pa.

Pa.

Remittent Fever.
Acute Bronchitis.
Fracture.
Cataract.

Total, 154.

E. ROGERS, M. D., Dean.

UNIVERSITY OF PENNSYLVANIA— MEDICAL DEPARTMENT.

NINETY-SECOND SESSION (1857-58).

The Lectures will commence on Monday, October 12, and continue until the middle
of March.

Robert Hare, M. D., Emeritus Professor of Chemistry.
William Gibson, M. D., Emeritus Professor of Surgery.

Samuel Jackson, M. D., Professor of Institutes of Medicine.

George B. Wood, M. D., Professor of Theory and Practice of Medicine.

rj x tt t\t f Professor of Obstetrics and the Diseases of Women and

Hugh L. Hodge, M. D., j Children.

Joseph Carson, M. D., Professor of Materia Medica and Pharmacy.
Robert E. Rogers, M. D., Professor of Chemistry.
Joseph Leidy, M. D., Professor of Anatomy.

Henry H. Smith, M. D., Professor of Surgery.

William Hunt, M. D., Demonstrator of Anatomy.

Clinical Instruction is given at the Pennsylvania Hospital, and at the Philadelphia
Hospital.

Clinical instruction is also given, throughout the Session, in the Medical Hall, by
the Professors.

The Dissecting Rooms, under the superintendence of the Professor of Anatomy and
the Demonstrator, are open after the middle of September.

Fees for the Lecture-, (each Professor $15) $105

Matriculation Fee (paid only once) 5

Graduation Fee 30

R. E. ROGERS, M. D., Dean of the Medical Faculty,
University Building.

F. B. DICK, Janitor, University Building.

American Journal of Med. Sciences.

297

JEFFERSON MEDICAL COLLEGE.

The Course of Lectures will commence on Monday, the 12th of October, and con-
tinue until the 1st of March.

Thos. D. Mutter, M. D., Emeritus Professor of Surgery.

-r, ,, TT at -ri f Emeritus Professor of Materia Medica and General

Egbert M. Huston, M. D., j Therapeutics.

Institutes of Medicine, etc., . . . -By Prof. Roblet Dunglison, M. D.

General, Descriptive and Surgical Anatomy, . " Joseph Pancoast, M. D.

Practice of Medicine, ..... " J. K. Mitchell, M. D.

Obstetrics and Diseases of Women and Children, " Charles D. Meigs, M. D.

Chemistry, " Franklin Bache, M. D.

Institutes and Practice of Surgery, . . " Samuel D. Gross, M. D.
Materia Medica and General Therapeutics,

Demonstrator of Anatomy, . . Ellerslie Wallace, M. D.

Every Wednesday and Saturday in the month of October, and during the course,
Medical and Surgical cases -will be investigated, prescribed for, and lectured on before
the Class. During the year ending March the first, 1857, about sixteen hundred cases
were treated, and about two hundred operations were performed ; amongst them many
major operations — as amputation of the thigh and leg, extirpation of the upper jaw,
mamma1, &c, lithotomy, trephining, resection of the elbow-joint, and ligation of
the external iliac artery.

The lectures are so arranged as to permit the student to attend the medical and
surgical practice and lectures at the Pennsylvania Hospital.

On and after the 1st of October, the dissecting rooms will be open, under the direc-
tion of the Professor of Anatomy and the Demonstrator.

Fees:

Matriculation, which is paid only once, . $ 5

To each Member of the Faculty §15, ...... 105

Graduation, 30

Philadelphia, June, 1857.

ROBLEY DUNGLISON, M.D.,

Dean of the Faculty.

PHILADELPHIA COLLEGE OF MEDICINE.
Fifth Street, below Walnut.
SESSION 1 857-8.
FACULTY.

Alfred T. King, M.D., Emeritus Professor of Practice of Medicine.

George Hewston, M. D., Professor of Anatomy.

B. Howard Rand, M. D., " Medical Chemistry.

Henry Hartshorne, M. D., " Practice of Medicine.

Lewis D. Harlow, M. D., " Obstetrics, &c.

William S. Halsey, M. D., " Surgery.

W. Hembel Taggart M. D., " Materia Medica.

James Aitken Meigs, M. D., " Institutes of Medicine.

William Bradley, M. D., Demonstrator of Anatomy.

Fees: Matriculation, $5; one Full Course, $100; Perpetual Ticket, $150: Gradua-
tion, $30; Practical Anatomy, $10; Material for Dissection, free. Second course
Students are furnished with the Hospital Ticket without charge. Lectures will com-
mence early in October, and terminate in March. Hereafter this College will have
but one Commencement annually; the Summer Lectures being made supplementary,
only, to the Winter Course.

For further information, address B. HOWARD RAND, M.D., Dean.

298

Amer ican Journal of Med. Sciences.

PENNSYLVANIA COLLEGE— MEDICAL DEPABTMENT.

SESSION OF 1857-58.

The regular Course of Lectures will commence on Monday, October 12th, and will
be continued until the 1st of March.

FACULTY.

David Gilbert, M. D., Professor of Obstetrics and Diseases of Women and Children.

Alfred Stille, M. D., Professor of Theory and Practice of Medicine.

John Neill, M. D., Professor of Surgery.

John J. Reese, M. D., Professor of Medical Chemistry.

John B. Biddle, M. D., Professor of Therapeutics and Materia Medica.

Francis G. Smith, M. D., Professor of Institutes of Medicine.

T. Gr. Richardson, M. D., Professor of General and Special Anatomy.

H. W. De Saussure Ford, M. D; \ Demoristrators of Anatomy.
J. Frank Bell, M. D., J J

The Students of Pennsylvania College — both first course and second course — will be
furnished gratuitously with the ticket to the Pennsylvania Hospital. A Clinic will
also be held at the College, every Wednesday and Saturday morning throughout the
session.

FEES.

For the entire Course of Lectures .... $105 00

Matriculation (paid once only) 5 00

Graduation 30 00

The Dissecting Rooms will be opened in September, under the direction of the Pro-
fessor of Anatomy.

Preliminary Lectures will be delivered during the fortnight preceding the opening
of the session.

FRANCIS G. SMITH, M. D., Registrar,
July, 2t. No. 1504 Walnut Street, Philadelphia.

OGLETHORPE MEDICAL COLLEGE,

SAVANNAH, GEORGIA.
The regular course of Lectures in this Institution will commence on Monday,
November 2, and continue four months. A preliminary course will commence on the
20th October.

The requirements for graduation are similar to those of other Medical Colleges in
the United States.

Students will have ample clinical instruction, and surgical operations are always
performed before the class when practicable.

A very liberal Beneficiary foundation is established in the College.
Good board may be had at from $3 50 to $5 00 per week.

FACULTY.

Holmes Steele, M. D., Dean, Professor of Obstetrics and Diseases of Women and

Children.
Professor of Anatomy.

Professor of Principles and Practice of Medicine.
Professor of Principles and Practice of Surgery.
Professor of Physiology and General Pathology.
Professor of Materia Medica and Medical Jurispru-
dence.

Professor of Chemistry and Pharmacy.

J. S. Morel, M. D.,
H. L. Byrd, M. D.,
J. W. Benson, M. D.,
J. R. Smith, M. D.,
Ira E. Dupree, M. D

Jules Le Hardy, M. D.
Hugh A. Blair, M. D.,

Demonstrator of Anatomy.

FEES.

2t.

For the full course .

Demonstrator

Matriculation

City Hospital (optional)

Diploma

$105 00
10 00
5 00
5 00
30 00

American Journal of Med. Sciences.

299

UNIVERSITY OF LOUISIANA— MEDICAL DEPARTMENT.

The Annual Course of Lectures in this department will commence on Monday, November 17, 1856,
and will terminate in the ensuing March.

James Jones, M. D., Professor of Practice of Medicine.

J. L. Riddle, M. D., Professor of Chemistry.

Warren Stone, M. D., Professor of Surgery.

A. H. Cenas, M. D., Professor of Obstetrics.

Gustavo's A. Nott, M. D., Professor of Materia Medica.

J. C. P. Wederstrandt, M. D., Professor of Anatomy.

Thomas Hunt, M. D., Professor of Physiology and Pathology.

Gilbert S. Vance, M. D., Demonstrator of Anatomy.

The rooms for Dissecting will be open on the third Monday in October.

The Faculty are Visiting Physicians and Surgeons of the Charity Hospital, and attend this Institu-
tion from November to April.

The Students accompany the Professors in their visits, and, free of expense, enjoy extraordinary
practical advantages.

There are, during the season, about eight hundred persons prescribed for daily.

Preliminary to the Course, Lectures will be delivered daily in the amphitheatre of the Hospital,
from the first Monday in- November, on Clinical Medicine and Surgery, Auscultation and Percussion,
and other subjects, without any charge to students.

THOMAS HUNT, M. D., Dean.

The Administrators of the Charity Hospital elect annually, in April, fourteen Resident Students,
who are maintained by the Institution.

MEDICAL COLLEGE OF VIRGINIA.

SESSION OP 1857-'58.

The regular Course of Lectures will commence on the 1st of October, and continue until the 1st of
March.

Charles Bell Gibson, M. D., Professor of Surgery and Surgical Anatomy.
David H. Tucker, M. D., Professor of Theory and Practice of Medicine.

Martin P. Scott, M. D., Professor of Chemistry and Pharmacy.

Beverley R. Wellford, M.D., Professor of Materia Medica and Therapeutics.
Arthur E. Peticolas, M. D., Professor of Anatomy.

Levin S. Joynes, M. D., Professor of Institutes of Medicine and Medical Jurisprudence.

James H. Conway, M. D. Professor of Obstetrics and Diseases of Women and Children.

Marion Howard, M. D., Demonstrator of Anatomy.

The study of Practical Anatomy may be prosecuted with the most ample facilities, and at a very
trifling expense.

The Infirmary, under the same roof with the College, is at all times well filled with Medical and
Surgical cases, and furnishes peculiar advantages for Clinical Instruction. Many Surgical Operations
are performed in the presence of the Class, and the Students, being daily admitted to the wards,
enjoy, under the guidance of the Professors, unusual opportunities for becoming familiar, not only
with the symptoms and diagnosis of disease, but with its daily progress and treatment. Students
also enjoy the Clinical advantages afforded by the Richmond Almshouse.

FEES.

For the entire Course of Lectures $105

Practical Anatomy 10

Matriculation Fee 5

Graduation Fee 25

L. S. JOTNES, M.D.,

April, 1857.— 3t. Dean of tlie Faculty.

300

American Journal of Med. Sciences.

MEDICAL COLLEGE OF THE STATE OF SOUTH CAROLINA.

The annual Course of Lectures in this Institution will commence on the second Mon-

ng branches: —

J. E. Holbrook, M. D.
E. Geddings, M. D.
S. Henry Dickson, M. D.
Henry R. Frost, M. D.
Thomas G. Prioleau, M.
C. XL Shepard, M. D.
Francis T. Miles, M. D.
J. F. M. Geddings, M. D.

day in November, on the followi
Anatomy-
Surgery . . .
Institutes and Practice
Materia Medica
Obstetrics
Chemistry

Demonstrator of Anatomy
Prosector to the Professor of Surgery

D. J. Cain, M. D., Physician to the Marine Hospital and Clinical Instructor, lectures
twice a week on the diseases of that Institution.

At the Roper Hospital Clinical Lectures are delivered twice a week by the Physician
and Surgeon of the Institution, and operations performed before the class in the
Amphitheatre of the Hospital.

The Faculty Ward in the Roper Hospital, by the conveniences which have been
furnished, is a valuable addition to the surgical practice of the city. Operations
are performed before the class, and students have opportunities of being made familiar
with the subsequent treatment.

The Anatomical Rooms will be opened in October, and dissections conducted daily
by the Demonstrator. Much attention is directed to this department; the material
being abundant, and illustrations of a varied character being afforded for acquiring a
competent knowledge of this very important branch.

The Faculty of the Medical College of the State of South Carolina take pleasure in
calling the attention of the friends of the Institution to its present prosperous con-
dition. They have been enabled, by the liberality of the Legislature, to make such
alterations in extending and improving the College building as will promote materially
the comfort of those in attendance on the Lectures.

The Anatomical Theatre has been enlarged and completely renovated, and such
changes made as will secure free ventilation, with a pleasant arrangement of the seats.
They confidently believe that it will not suffer in comparison with any like structure
in the United States, the edifice, with its appurtenances, being as commodious and
attractive as any such establishment in the country. By the same appropriation of
the Legislature, they have been enabled to make considerable addition to the Museum
of the College.

In the Surgical department considerable additions have been made in drawings,
plates, &c, and the collection of articles in the Materia Medica has been made very
extensive and complete.

HENRY R. FROST, Dean.

PREMIUM OFFERED BY THE PROFESSOR OF SURGERY.

The undersigned, Professor of Surgery in the Medical College of the State of South
Carolina, with the view of encouraging diligence of study, and promoting a greater
spirit of scientific investigation and research, offers to the graduating class, for the
ensuing year, two prizes, of the value of one hundred dollars each, for the two best
essays on the following subjects, and under the restrictions subjoined, viz : —

1. For the best essay on a surgical subject a prize of one hundred dollars.

2. For the best essay on the Anatomy, Physiology, and Pathology of the Supra-
renal Capsules, a prize of one hundred dollars.

It is expected that these essays shall contain a full and faithful digest of the existing
knowledge on the subject; that they shall, as far as possible, be enriched by original
observations and suggestions, and shall be written in the English language.

Such essay is to be separate and independent of that which is required by the
Faculty for graduation.

Each essay presented must be accompanied by a sealed packet, containing a motto
corresponding to one indorsed on the essay, which former will only be opened in that
to which the prize may be adjudged.

All essays must be handed in on or before the 15th day of February, when they
will be placed before a disinterested committee for the adjudication of the prizes.

E. GEDDINGS, M. D.,
Frof. of Surgery in Med. College of the State of South Carolina.

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR OCTOBER 1 857.

CONTRIBUTORS TO THIS VOLUME.

E. P. BENNETT, M. D., of D anbury, Conn.
HANFORD N. BENNETT, M. D., of Bridgeport, Conn.
HENRY BOND, M. D., of Philadelphia.

ROBERT BRIDGES, M. D., Professor of Chemistry in the Philadelphia College of

Pharmacy.

BEDFORD BROWN, M. D., of Caswell Co., N. C.

EDWARD BROWN-SEQUARD, M. D., Professor of Physiology, $c. $c.

JOSEPH CARSON, M. D., Professor of Materia Medica in University of Pennsylvania.

HON. LEWIS CASS, Secretary of State U. S.

ISAAC CASSELBERRY, M. D., of Evansville, Ind.

D. FRANCIS CONDIE, M.D., of Philadelphia.

R. CROCKETT, M. D., of Wytheville, Va.

CHARLES R. S. CURTIS, M. D., Chief Surgeon of the N. W. Eye Infirmary, Chicago.
JOHN C. DALTON, M. D., Professor of Physiology and Microscopic Anatomy in the

College of Physicians and Surgeons, New York.
SILAS DURKEE, M. D., of Boston.
PLINY EARLE, M. D., of Massachusetts.
JAMES H. TINKHAM, M. D., of Geneva, N. Y.

AUSTIN FLINT, M. D., Professor of Clinical Medicine and Pathology in the University
of Buffalo.

AUSTIN FLINT, Jr., M. D., of Buffalo, N. Y.

THOMAS J. GALLAGHER, M. D., one of the Physicians to the Western Pennsylvania

Hospital, Pittsburg.
H. T. GOLDSBOROUGH, M. D., of Easton, Md.
J. F. GRANT, M. D., of Bradshaw, Term.

HENRY HARTSHORNE, M. D., Prof. Pract. Med. in Philadelphia Medical College.
FRANK HASTINGS HAMILTON, M. D., Professor of Surgery in Medical Department

in the University of Buffalo.
WORTHINGTON HOOKER, M. D., Professor of Theory and Practice of Physic in the

Medical Institution of Yale College.
DAVID HUTCHINSON, M. D., of Mooresville, Ind.

SAMUEL JACKSON, M. D., Professor of Institutes of Medicine in the University of

Pennsylvania.
S. L. KERR, M. D., of El Paso, III.

CHARLES A. LEE, M. D., Professor of Materia Medica, ftc, in Perkshire Medical In-
stitution.

JOSEPH LEIDY, M. D., Professor of Anatomy in the University of Pennsylvania.
W. LEHMAN WELLS, M. D., Resident Physician to the Pennsylvania Hospital.
FREDERICK D. LENTE, M. D., of Cold Spring, N. Y.
S. LEWIS, M. D., of Philadelphia.

A. W. McDOWELL, M. D., of Bedminster, iV. J.

JOHN H. PACKARD, M. D., late Resident Physician at the Pennsylvania Hospital.
D. B. PHILLIPS, M. D., Passed Assistant Surgeon U. S. S.
DANIEL PIERSON, M. D., of Augusta, HI.

B. F. SCHNECK, M. D., of Lebanon, Pa.
CHARLES H. SMITH, M. D., Assistant Surgeon U. S. A.

HORATIO R. STORER, M. D., one of the Physicians to the Boston Lying-in Hospital.
EDWARD WARREN, M. D., of Edenton, N. C.
J. WHITAKER, M. D., of Lewisiown, A7". Y.
G. A. WILBUR, M. D., of Skowhegan, Me.

TO READERS AND CORRESPONDENTS,

The communications of Professors Clarke, Flint, and Gilbert, and of Drs.
Coolidge, Heywood, Atlee, and Fleming, shall appear in our next number.

Communications have been received from Drs. Casselberry, Dowell, Bar-
ber, Shepherd, King, McRae, and Red, which shall receive early attention.

The following works have been received: —

On Gastro-colic Fistula. A Collection of Cases and Observations on its Pa-
thology, Diagnosis, &c. By Charles Murchison, M. D., &c. &c. Edinburgh,
1857. (From the Author.)

Elements of Pathological Anatomy. By Samuel D. Gross, M. D., Professor
of Surgery in the Jefferson Medical College of Philadelphia, and formerly
Professor of Pathological Anatomy in the Medical Department of the Cincin-
nati College. Third edition, modified and thoroughly revised ; illustrated by
three hundred and forty-two engravings on wood. Philadelphia: Blanchard &
Lea, 1857. (From the Publishers.)

Fiske Fund Prize Essays : The Effects of Climate on Tuberculous Disease.
By Edwin Lee, M. R. C. S.London. The Influence of Pregnancy on the De-
velopment of Tubercles. By Edward Warren, M.D., of Edenton, N. C.
Philadelphia: Blanchard & Lea, 1857. (From the Publishers.)

General Therapeutics and Materia Medica ; adapted as a Medical Text-Book,
with Indexes of Remedies, and of Diseases and their Remedies. By Robley
Dunglison, M. D., LL.D., Prof. Ins. Med. Jeff. Med. Col. With 193 illustra-
tions. Sixth edition, revised and improved; in two volumes. Philadelphia:
Blanchard & Lea, 1857. (From the Publishers.)

The Practice of Surgery. By James Miller, F. R. S. E., F. R. C. S. E., Prof,
of Surg, in Univ. of Edinburgh, etc. etc. etc. Revised by the American Editor.
Fourth American from the last Edinburgh edition. Illustrated by 364 en-
gravings on wood. Philadelphia: Blanchard & Lea, 1857. (From the Pub-
lishers.)

A Theoretical and Practical Treatise on Midwifery, including the Diseases
of Pregnancy and Parturition, and the attentions required by the Child from
Birth to the period of Weaning. By P. Cazeaux, Adj. Prof, in Fac. Med. of
Paris. Second American edition, translated from the fifth French edition by
Wm. R. Bullock, M. D. With 140 illustrations. Philadelphia: Lindsay &
Blakiston, 1857. (From the Publishers.)

Transactions of the South Carolina Medical Association at the extra meet-
ing in Sumter, July 9, 1856, and at the annual meeting in Charleston, Feb. 4,
1857. Charleston, 1857.

Transactions of the Second Session of the Medical Society of the State of
California, convened at Sacramento Feb. 11, 1857. Sacramento, 1857. (From
Dr. T. M. Logan.)

Proceedings of the Sixty-Fourth Annual Convention of the Connecticut
Medical Society, May, 1857. Hartford, 1857.

Transactions of the Medical Society of the State of New York. (Transmit-
ted to the Legislature Feb. 9, 1857 ) Albany, 1857.

Transactions of the Indiana State Medical Society at its Eighth Annual
Session held in the city of Indianapolis, May 19, 1857. Indianapolis, 1857.

Transactions of the Eighth Annual Meeting of the Medical Society of the
State of North Carolina, held at Edenton, N. C, April, 1857. Wilmington,
1857.

Transactions of the New Hampshire Medical Society (sixty-seventh anni-
versary), held at Concord, June 2 and 3, 1857. Concord, 1857. (From Dr. T.
J. W. Pray.)

296

TO READERS AND CORRESPONDENTS.

Annual Report of the Commissioners of Emigration of the State of New
York, with the Medical and Surgical Reports for the year ending Dec. 31,

1856. New York, 1857.

Report on the Origin of the Yellow Fever in Norfolk during the Summer of
1855, made to City Councils by a Committee of Physicians. Richmond, Ya.,
1857.

Report on the Yital Statistics of the United States, made to the Mutual Life
Insurance Company of New York. By James Wynne, M. D., etc. New York,

1857. (From the Author.)

Life — its Relations, Animal and Mental; an Inaugural Dissertation. By J.
Dickson Bruns, A. M , M. D. Charleston, 1857. (From the Author.)

Reports of the Trustees and Superintendent of the Maine Insane Hospital,
Dec. 1856. Augusta, 1856.

Thirtieth Annual Report of the Directors of James Murray's Royal Asylum
for Lunatics, near Perth. June, 1857. Perth, 1857.

Ninth Annual Report of the Massachusetts School for Idiotic and Feeble-
minded Youth. Boston, 1857.

The Fourth Annual Report of the Board of Directors of the Pennsylvania
Training School for Idiotic and Feeble-minded Children to the Corporators.
Philadelphia, 1857.

Annual Report of the Board of Regents of the Smithsonian Institution,
showing the Operations, Expenditures, and Condition of the Institution for
the year 1856. And the Proceedings of the Board up to January 28, 1857.
Washington, 1857.

History and Treatment of Yesico-Yaginal Fistula: a Report read before the
Medical Society of the State of Georgia at their Annual Meeting at Augusta,
April 8, 1857. By P. M. Kollock, M. D., Professor of Obstetrics and Diseases
of Women and Children in the Savannah Medical College, and Member of the
American Medical Association. Augusta, 1857. (From the Author.)

Remarks upon Fractures of the Scapula, with Cases presenting Striking
Peculiarities. Read before the Medical Society of the State of Georgia, at
their Annual Meeting in Augusta, April 8, 1857. By L. A. Dugas, M. D.,
Prof, of Surgery in the Medical College of Georgia. Augusta, 1857. (From
the Author.)

Exsection of the Entire Os Calcis. By J. M. Carnochan, M. D., Surgeon-in-
Chief to the State Hospital, Prof, of Surgery in the N. Y. Medical College, etc.
(From the Author.)

Early History of the Operation of Ligature of the Primitive Carotid Artery ;
with a Report of Forty-eight Unpublished Cases, and a Summary of Forty-four
Cases; with Remarks by Yalentine Mott. By J. R. Wood, M. D. New
York, 1857. (From the Author.)

On the Successful Treatment of Hydrarthrosis of the Knee-joint by Punc-
ture and Injection of Iodine. By R. L. Mac Donnell, M. D. Montreal, 1857.
(From the Author.)

The Principles and Objects of the Massachusetts Medical Society. Delivered
at their Annual Meeting, June 3, 1857, by M. S. Perry, M. D. Reprinted
from the " Medical Communications. " Boston, 1857.

An Address delivered before the Medical Society of the State of Pennsyl-
vania, at its- Annual Session held in West Chester, in May, 1857. By R. La
Roche, M. D., President of the Society. Philadelphia, 1857.

An Address on the Life and Character of the late Prof. John Locke. De-
livered at the request of the Cincinnati Medical Society. By M. B. Wright,
M. D. Cincinnati, 1857.

Annual Address before the San Francisco County Medical Society. Delivered
pursuant to appointment January 27, 1857. By Henry Gibbons, M. D. San
Francisco, 1857.

Therapeutic Cultivation, its Errors and its Reformation. An Address de-
livered to the Tennessee Medical Society, April 7, 1857. By E. B. Hoskins,
M. D., President. Nashville, 1857.

Report on the Practice of Medicine to the Indiana State Medical Society.
By T. J. Cogley, M. D. Madison, 1857.

TO READERS AND CORRESPONDENTS.

297

The Physician's Visiting List, Diary, and Book of Engagements, for 1858.
Lindsay & Blakiston, 1857. (From the Publishers.)

The Constitution and By-Laws of the Montgomery County (Ohio) Medical
Society, and the Code of Ethics of the American Medical Association. Dayton,
1857.

Annual Circular of the Trustees and Faculty of the Medical College of the
State of South Carolina, with a Catalogue of the Students and List of Gra-
duates. Session 1856-7. Charleston, S. C, 1857.

Annual Circular and Report of the New Orleans School of Medicine, char-
tered May, 1856.

Thirty-Eighth Annual Announcement of Lectures of the Medical College of
Ohio for the Session of 1857-8, and Catalogue of Students and Graduates of
the Medical College of Ohio and Miami Medical College for the Sessions of
1856-7. Cincinnati, 1857.

Report and Announcement of the Medical Department of the University of
Pennsylvania for the Session of 1857-8. Philadelphia, July, 1857.

The following Journals have been received in exchange: —

Le Moniteur des Hopitaux Revue Medico-Chirurgicale de Paris. Redacteur
en chef, M. H. De Castleneau. June, July, August, 1857.

Annales Medieo-Psychologiques. Par MM. les Docteurs Baillarger, Ce-
rise, et Moread (de Tours). July, 1857.

Journal de Medecine de Bordeaux. Redacteur en chef, M. Costes. July,
1857.

Revue de Therapeutique Medico-Chirurgicale. Par A. Martin Lauzer. Ja-
nuary, February, March, April, May, June, July, August, 1857.

Gazette Medicale de Paris. January, February, March, May, June, July,
August, 1857.

L'Art Dentaire Revue Mensuelle de laChirurgie et de la Prothese Dentaires.
Par MM. Fowler et Preterre, Dentistes Americaines a Paris. June, July,
1857.

The British and Foreign Medico-Chirurgical Review. July, 1857.

The Half-Yearly Abstract of the Medical Sciences. By W. II. Ranking,
M. D. and C. Radcliffe, M. D. January, June, 1857.

The Retrospect of Medicine. Edited by W. Braithwaite, Lecturer on Ob-
stetric Medicine. January, June, 1857.

The Journal of Psychological Medicine and Mental Pathology. Edited by
Forbes Winslow, M. D. July, 1857.

Edinburgh Medical Journal. June, July, August, 1857.

The Liverpool Medico-Chirurgical Journal. July, 1857.

The Midland Quarterly Journal of the Medical Sciences. May, 1857.

British Medical J ournal. Edited by Andrew Winter, M. D. J uly, August,
September, 1857.

The Dublin Hospital Gazette. June, July, August, 1857.

The Dublin Quarterly Journal of Medical Science. August, 1857.

The Indian Annals of Medical Science. April, 1857.

The Sanitary Review and Journal of Public Health. Edited by B. W.
Richardson, M. D. July, 1857.

The Glasgow Medical Journal. July, 1857.

The Medical Chronicle. Edited by Wm. Wright, M. D., and D. C. McCal-
lum, M. D. July, August, September, 1857.

The New York Journal of Medicine. Edited by Stephen Smith, M. D.
July, September, 1857.

Buffalo Medical Journal. Edited by Sandford B. Hunt, M. D. July, Au-
gust, September, 1857.

New Orleans Medical News and Hospital Gazette. Edited by Drs. Choppin,
Beard, and Brickell. July, August, September, 1857.

Southern Medical and Surgical Journal. Edited by Henry F. Campbell,
M. D. and Robert Campbell, M. D. July, August, September, 1857.

Nashville Journal of Medicine and Surgery. Edited by W. K. Bowling,
M. D., and Paul F, Eve, M. D. July, August, 1857.

298

TO READERS AND CORRESPONDENTS.

The Western Lancet. Edited by Geo. C. Blackman, M. D. July, August,
1857. J

The St. Louis Medical and Surgical Journal. Edited by M. L, Linton,
M. D., and Wm. M. McPheeters, M. D. July, 1857.

The American Journal of Insanity. July, 1857.

Memphis Medical Recorder. Edited by D. F. Wright, M. D. July, 1857.

The American Journal of Pharmacy. Edited by Wm. Procter, Jr., Prof, of
Pharmacy in Philadelphia College of Pharmacy. July, September, 1857.

The American Medical Gazette. Edited by J. Meredith Reese, M. D. July,
August, September, 1857.

The American Journal of Science and the Arts. Conducted by Professor
B. Silliman, B. Silliman, Jr., and James D. Dana. July, September, 1857.

The Cincinnati Medical Observer. Edited by Drs. Mendenhall, Murphy,
and Stevens. July, August, September, 1857.

The Southern Journal of Medical and Physical Sciences. Edited by R. 0.
Currey, M. D. July, August, 1857.

The North Western Medical and Surgical Journal. Edited by N. S. Davis,
M. D. July, 1857.

The Medical and Surgical Reporter. Edited by S. W. Butler, M. D. July,
August, September, 1857.

The American Journal of Dental Science. Edited by Drs. C. A. Harris,
and A. S. Piggot. July, 1857.

The North American Medico-Chirurgical Review. Edited by S. D. Gross,
M.D., and T. G. Richardson, M. D. July, September, 1857.

The Boston Medical and Surgical Journal. Edited by W. W. Morland,
M. D., and Francis Minot, M. D. July, August, September, 1857.

Charleston Medical Journal and Review. Edited by C. Happoldt, M. D.
July, September, 1857.

The Virginia Medical Journal. Edited by Drs. McCaw and Otis. July,
August, September, 1857.

The New Orleans Medical and Surgical Journal. Edited by Bennet Dow-
ler, M. D. July, September, 1857.

The Ohio Medical and Surgical Journal. Edited by John Dawson, M. D.
July, September, 1857.

Iowa Medical Journal. Edited by Drs. Hughes and Marsh. May, June,
July, August, 1857.

The Peninsular Journal of Medicine. Edited by Drs. Pitcher, Palmer,
Brodie, and Christian. July, August, 1857.

Atlanta Medical and Surgical Journal. July, September, 1857.

The New Hampshire Journal of Medicine. Edited by Geo. H. Hubbard.
July, August, September, 1857.

The Medical Independent. Edited by Moses Gunn, M. D., and L. G. Robin-
son, M. D. September, 1857.

Communications intended for publication, and Books for Review, should be sent,/ree
of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the Me-
dical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed as
above, and (carriage paid) under cover, to John Miller, Henrietta Street, Covent Gar-
den, London; or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will reach us
safely and without delay. We particularly request the attention of our foreign corre-
spondents to the above, as we are often subjected to unnecessary expense for postage
and carriage.

Private communications to the Editor, maybe addressed to his residence, 1525
Locust St.

All remittances of *ioney, and letters on the business of the Journal, should be
addressed exclusively to the publishers, Messrs. Blanchard & Lea.

The advertisement-sheet belongs to the business department of the Journal,
and all communications for it should be made to the publishers.

To secure insertion, all advertisements should be received by the 20th of the pre-
vious month.

CONTENTS

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.
NO. LXVIII. NEW SERIES.
OCTOBER, 1857.

ORIGINAL COMMUNICATIONS

MEMOIRS AND CASES.
Art. page

I. On the Constitution and Physiology of the Bile. By Jno. C. Dalton, Jr.,
M. D., Professor of Physiology and Microscopic Anatomy in the College

of Physicians and Surgeons, New York. (With seven wood-cuts.) - 305

II. Compound Dislocation of the Long Bones ; considered with Especial
Reference to the Value of Resection. By Frank Hastings Hamilton,

M. D., Prof, of Surgery in the Med. Dep. University of Buffalo. - - 324

III. Clinical Remarks on the Natural Range of the Heart's Sounds. By
Chas. A. Lee, M. D., Professor of Materia Medica in the Medical Depart-
ment of the University of Buffalo. -------- 337

IV. Description of a New Splint for Dressing Diseases and Injuries of the
Elbow-Joint. By Henry Bond, M. D., of Phila. (With a wood-cut.) - 344

V. Successful Employment of Marshall Hall's Ready Method in the Case
of an Infant born Asphyxiated. By Frederic D. Lente, M. D., of Cold
Spring, N. Y. (With a wood-cut.) - - 347

VI. Extirpation of the Entire Clavicle. By Charles R. S. Curtis, M. D.,
Chief Surgeon to the North-western Eye Infirmary and Orthopaedic In-
stitution, Chicago. -- --------- 350

VII. Smallpox and its Varieties. By A. W. McDowell, M. D., of Bed-
minster, Somerset County, New Jersey. ----- -353

VIII. Case of Successful Ovariotomy. By Hanford N. Bennett, M. D., of
Bridgeport, Conn. 357

IX. Two Cases of Recovery from Fracture of the Spine, with Remarks on
this Fracture. By Frederic D. Lente, M. D., Surgeon to the West Point
Foundry. - - - - - - - 361

X. Poisoning by Chloroform. By Charles H. Smith, M. D., Assistant Sur-
geon U. S. A. (Communicated by Thos. Lawson, M. D., Surgeon-General
U.S.A.) - - - - - - - - - - - - 367

XL Fiske Fund Prize Essay : What are the Causes and Nature of that
Disease incident to Pregnancy and Lactation, characterized by Inflam-
mation and Ulceration of the Mouth and Fauces, usually accompanied
by Anorexia, Emaciation, and Diarrhoea; and what is the best mode of
treatment? By David Hutchinson, M. D., of Mooresville, Morgan
County, Ind. The Dissertation to which the Fiske Fund Prize was
awarded, June 3, 1857. (Published by request of the Rhode Island
Medical Society.) - - - 369

300

CONTENTS.

REVIEWS.

ART. PAGE

XII. The Treatment of Vaginal Fistula.

1. On the Treatment of Vesico-Vaginal Fistula. By J. Marion Sims,
M. D., of Montgomery, Ala. (With twenty-two wood-cuts), pp. 24.
From the American Journal of the Medical Sciences for Jan. 1852.

2. Remarks on Vesico-Vaginal Fistula, with an account of Seven Suc-
cessful Operations. By N. Bozeman, M. D., of Montgomery, Ala.
(With wood-cuts), pp. 29. From the Louisville Review for May, 1856.

3. Urethro-Vaginal and Vesico-Vaginal Fistules — Remarks upon their
Peculiarities and Complications, &c. &c. By the same author. (With
seventeen wood-cuts), pp. 23. From the North American Medico-Chi-
rurgical Review for July, 1857.

4. The History and Treatment of Vesico-Vaginal Fistula; a Report read
before the Medical Society of the State of Georgia. By P. M. Kollock,
M. D., Professor of Obstetrics in the Savannah Medical College. (With

nine wood-cuts), pp. 32. Augusta, 1857. 387

XIII. Adulterations Detected; or Plain Instructions given for the Dis-
covery of Frauds in Food and Medicine. By Arthur Hill Hassall,
M. D. London, 1857.

On the Composition of Food, and how it is Adulterated; with Practical
Directions for its Analysis. By W. Marcet, M. D., F. C. S. London,
1856. 394

XIV. Of Nature and Art in the Cure of Disease. By Sir John Forbes,
M. D., and C. L. Oxon, F. R. S., Fellow of the Royal College of Physi-
cians, Physician to the Queen's Household, &c. &c. : London, 1857,

pp. 264. - - - - 409

XV. Cours Theorique et Clinique de Pathologie Interne, et de Therapie
Medicale. Par G. Gintrac, Professeur de Clinique Interne, et Directeur
de l'Ecole de Medecine de Bordeaux, etc. etc. etc. Tomes 1, 2, 3.
Pp. 669, 696, 840. _ Paris, 1853.

A Theoretical and Clinical Course of Internal Pathology and Medical The-
rapeutics. By G. Gintrac, Professor of Internal Clinics, and Director
of the School of Medicine of Bordeaux, etc. etc. etc. Volumes 1, 2, 3. 420

XVI. Diseases of the Skin. By Erasmus Wilson, F. R. S. Fourth Ame-
rican, from the fourth and enlarged London edition. Philadelphia :
Blanchard & Lea, 1857. 427

BIBLIOGRAPHICAL NOTICES.

XVII. Transactions of State Medical Societies.

1. Transactions of the Medical Society of the State of New York, trans-
mitted to the Legislature, Feb. 9, 1857. 8vo. pp. 292.

2. Proceedings of the Sixty-Fourth Annual Convention of the Connecti-
cut Medical Society, May, 1857. 8vo. pp. 71.

3. Transactions of the Eighth Annual Meeting of the Medical Society
of the State of North Carolina. Held at Edenton, N. C, April, 1857.
Wilmington, N. C, 1857, pp. 90, 8vo.

4. Transactions of the Medical Society of the State of Pennsylvania at
its Annual Session, held in Westchester, Chester Co., May, 1857.
8vo. pp. 218. 437

XVIII. Catalogue Raisonne of the Medical Library of the Pennsylvania
Hospital. By Emil Fischer, M. D. Printed by order of the Board of
Managers. 8vo. pp. 750. Philadelphia, 1857. 458

CONTENTS.

301

ART. PAGE

XIX. Reports of American Institutions for the Insane.

1. Of the Maine State Hospital, for the year 1856.

2. Of the Vermont State Asylum, for the fiscal year 1855-6.

3. Of the McLean Asylum, for the year 1856.

4. Of the Butler Hospital, for the year 1856.

5. Of the Hartford Retreat, for the fiscal year 1855-6.

6. Of the King's County Asylum, N. Y., for the fiscal year 1855-6. - 461

XX. Indigenous Races of the Earth; or, New Chapters of Ethnological
Inquiry, including Monographs on Special Departments of Philology,
Iconography, Cranioscopy, Palaeontology, Pathology, Archaeology, Com-
parative Geography, and Natural History ; contributed by Alfred Maury,
Biblioth6caire de l'lnstitutde France, Secretaire General de la Societe de
Geographie de Paris, &c. ; Francis Pulszky, of Lubocz and Cselfalva,
Fellow of the Hungarian Academy, &c. ; and J. Aitken Meigs, M. D.,
Professor of the Institutes of Medicine in the Philadelphia College of
Medicine, Librarian of the Academy of Natural Sciences of Philad., &c.
[with communications from Prof. Jos. Leidy, M. D., and Prof. L. Agas-
siz, LL.D.] ; presenting fresh investigations, documents, and materials;
by J. C. Nott, M. D„ &c, and Geo. R. Gliddon, &c. &c. Philadelphia:

J. B. Lippincott & Co., 1857. 468

XXI. Annual Report of the Physician-in-Chief of the Marine Hospital at
Quarantine. Presented to the Legislature of New York, Feb. 4, 1857.
8vo. pp. 64. Albany, 1857. 471

XXII. Report on the Origin of the Yellow Fever in Norfolk during the
Summer of 1855, made to the City Councils by a Committee of Physi-
cians. 8vo. pp. 44. Richmond, Va., 1857. 475

XXIII. Principles of Medicine. An Elementary View of the Causes,
Nature, Treatment, Diagnosis and Prognosis of Disease, with Brief Re-
marks on Hygienics or the Preservation of Health. By Charles J. B.
Williams, M.D., F. R. S. A new American from the third and revised
London edition. Philadelphia: Blanchard & Lea, 1857. 8vo. pp. 486. 479

XXIV. Report of the Recent Yellow Fever Epidemic of British Guiana.
By Daniel Blair, M. D., Surgeon-General of British Guiana. 8vo. pp.
91: London, 1856. 481

XXV. On some points in the Anatomy of the Liver of Man and Verte-
brate Animals, with Directions for injecting the Hepatic Ducts, and
making Preparations. By Lionel S. Beale, M. D., London. Illustrated
with upwards of 60 photographs of the author's drawings. London:
John Churchill, 1856; pp. 80, 8vo. 491

XXVI. General Therapeutics and Materia Medica: adapted for a Medi-
cal Text Book. With Indices of Remedies, and of Diseases and their
Remedies. By Robley Dunglison, M. D., LL.D., Professor of Institutes
of Medicine, etc., in Jefferson Medical College of Philadelphia, etc. etc.
With one hundred and ninety-three illustrations. Sixth edition, revised
and improved. 2 vols. 8vo. pp. 544, 539. Blanchard & Lea, Philad. - 491

XXVII. Researches into the Structure and Physiology of the Kidney. By
C. E. Isaacs, M. D., Demonstrator of Anatomy in the University of the
City of New York.

On the Function of the Malpighian Bodies of the Kidney. By C. E. Isaacs,
M. D., &c. New York, 1857. - 492

XXVIII. On the Extent of the Pleura above the Clavicle. By C. E. Isaacs,

M. D., Demonstrator of Anatomy, &c. - - - - - - - 492

302

CONTENTS.

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.

FOREIGN INTELLIGENCE.

Anatomy and Physiology.

page

1. Anatomy of the Supra-Renal
Capsules. By Prof. Ludovic
Hirschfield. - - - - 493

2. Fibrin, its Nature and the Cause
of its Coagulation. By Zimmer-
mann. 495

3. Assimilation of different Olea-
ginous Substances. By Berthe. 496

4. On certain Physiological Phe-
nomena connected with Parturi-
tion and Lactation in Bitches
that have not been Fecundated
when in Heat. By Delafond. - 49G

5. Erectile Apparatus of the Eye.

By Dr. C. Rouget. - - - 496

Materia Medic.

6. Employment of Amylene. By

M. Robert. - - - - 497

7. Ansesthetic Action of Carbonic
Oxide. By Dr. Ozanam. - - 499

8. On the Effect produced on the
Circulation by the Long-con-
tinued Action of Cold Water
Externally. By Dr. H. Bence
Jones and W. Howship Dickin-
son, Esq. 501

9. The Bittera Febrifuga as an
Antiperiodic. By M. Delioux. - 502

10. Therapeutic Employment of
Cocoa-Nut Oil. By Dr. Petten-
kofer. . - - - - 503

11. Physiological Action of the
Disulphate of Quinia. By Dr.

H. Ranke. - - - - 503

and Pharmacy.

12. Pyrophosphate of Iron and
Soda in Ansemia. By MM. Fol-

let and Baume. - 503

13. On the Preparation and The-
rapeutical Employment of Sub-
carbonate of Bismuth. By M.
Hannon. 504

14. A New Principle of Colchicum
autumnale. By M. Oberlin. - 505

15. Ether and Chloroform Gela-
tinized. By Prof. Ruspini. - 505

16. Manganese cum Potassa. By
Weeden Cooke. - 505

17. Corrosive Sublimate and Col-
lodion as an Escharotic. By Dr.
Macke. 506

Medical Pathology and Therapeutics, and Practical Medicine.

18. Etiology of Diabetes. Diabetic
Sugar not the same as the Sugar
produced in the Liver in Health.

By Dr. G. Owen Re^s. - - 506

19. Diabetes ; Concretion on Ner-
vus Vagus. By Hr. Nyman. - 508

20. On the Mortality from Erup-
tive Fevers at Different Periods

of the Year. By Dr. Tripe. - 510

21. Illustrations of Aguish Dis-
order Prevailing in London du-
ring the last two or three Years.

By Dr. C. Handfield Jones. - 511

22. On Spansemia, Chlorosis, and
Analogous Conditions, as the
Predominant Characteristic of
the Present Age. By Dr. Pol-
litzer. 513

CONTENTS.

308

PAGE

23. Redness of the Cheeks as a
Symptom of Pneumonia. By
Dr. A. Gubler. - - - 513

24. New Premonitory Symptoms

of Cholera. By Dr. Poznanski. 514

25. On the application of the Mi-
croscope to the Diagnosis of
Pulmonary Consumption. By
Dr. Theophilus Thompson. - 514

26. On Movable Kidneys. By
Prof. Oppolzer. - - - 517

PAGE

27. Open Foramen Ovale in the
Adult. By Dr. J. W. Ogle. -517

28. Combined Constitutional and
Local Treatment of Hooping-
Cough. By Dr. R. Pearoe. - 519 -

29. On Bloodletting in Pneumo-
nia. By Prof. Wunderlich. - 520

30. Glycerine in Consumption. By
Dr. R. P. Cotton. - - ^ - 521

31. Electricity in the Suppression
of the Lacteal Secretion. By

M. Becquerel. - - - - 521

Surgical Pathology and Therapeutics, and Operative Surgery.

32. Hereditary Transmission of
Tendencies to Cancerous and
other Tumours. By Dr. James
Paget. 522

33. Fracture of the Thigh for the
fourth time at the same part. 524

34. Spontaneous Fracture of both
Thigh-Bones. - - - - 524

35. Fracture of the Humerus from
Muscular Action. By Mr. H.
Smith. 525

36. Excision of the Head of the
Thigh-bone. By Mr. Alex. Ure. 525

37. Mr. Fergusson's Case of Ex-
cision of an Enlarged Third
Lobe of the Prostate. - - 526

38. Treatment of Hydrarthrosis of
the Knee-joint by Puncture and
Injection of Iodine. By Dr.
Robt. L. Macdonnell. - - 527

39. Tracheotomy in Croup. By

M. Andre. - - - - 523

40. Treatment of Hydrocele in
Children. By M. Richard. - 529

41. Enucleation Treatment of Ute-
rine Fibrous Tumours. By Mr.

J. Hutchinson. - 529

42. Ovariotomy. By Dr. Charles
Clay. _ 530

43. Concretions of the Prostate.

By Mr. H. Thompson. - - 530

44. Gonorrhoea of the Nose. By
Mr. Edwards. - - - - 531

45. New Crimean Tourniquet. By
Mr. Salt. 531

46. Rectangular Catheter Staff for
Lithotomy. By Mr. Hutchin-
son. 531

Ophthalmology.

47. Amaurosis with Bright's Dis-
ease of the Kidney. By Mr.
Holmes Coote. - 533

48. Diphtheritic Ophthalmia. By
MM. Warlomont and Testelin. 534

49. Photophobia and Blepharo-
spasm relieved by Chloroform.

By Dr. Mackenzie. - - - 535

50. Hemorrhage from the Eyeball

after the Extraction of Cataract.
By Mr. White Cooper. - - 535

51. Ultimate 111 Results of the De-
pression of Cataract. By Mr.
Bowman. ----- 537

52. Symblepharon treated success-
fully by Blandin's Method. By
Mr. R. Taylor. - - - 538

Midwifery.

53. Use of the Speculum. By Dr. 55. Statistics of Placenta Prsevia.
Robert Lee. - - - - 539 By Dr. Schwarz. - - - 540

54. Statistics of Coiling of the 56. Sudden Death after Parturi-
Funis. By Dr. Weidemann. - 540 tion, with Air in the Veins. By

Geo. May, Jr., Esq. - - - 541

304

CONTENTS.

Medical Jurisprudence and Toxicologt.

57. Partial Paralysis of the Ex-
v tremities, caused by the con-
tinued use of Snuff containing
Lead. By Dr. Moritz Meyer. -542

PAGE

58. Death from Amylene. By Dr.

J. Snow. 544

59. Trial of Miss Madeleine Smith. 545

AMERICAN INTELLIGENCE.
Original Communications.

On Starch as a Product of the
Liver, and on the Amyloid De-
generation of the Liver in Yel-
low Fever. By Samuel Jackson,
M. D. 549

Vaccine given Inwardly for the
Cure of Smallpox. By R. Lan-
dell, M. D. - - > - _ - 552

Case of Fracture connecting with
Frontal Sinus and Exposure of
Frontal Nerve. The Nerve Di-
vided. By W. Lehman Wells,
M.D. 553

Extrusion of an Ovum at the Fifth

Month of Utero Gestation with

the Membranes entire. By J.

F. Grant, M. D. - - - 554
Indian Corn in Intermittent Fever.

By D. B. Phillips, M. D. - - 554
Account of a Case in which both

Ovaries were Extirpated by Dr.

H. A. Potter. By James II.

Tinkham, M. D. * - - - 555
Case of Herpes Preputialis. By

H. T. Goldsborough, M. D. - 556

Domestic Summary.

Dislocation of the Processes of the
Cervical Vertebrae. By Dr. E.
R. Maxson. - - - - 557

Change of Colour in a Negro. By
Dr. W. L. Sutton. - - - 557

Case of Death by Syncope from
Plugging the Pulmonary Arte-
ry. By Dr. 0. M. Allaben. - 558

Delirium Tremens following an at-
tack of Pneumonia. By Dr. J.
J. Summerville. - 559

Poisoning from an overdose of the

Tincture of Cantharides. By Dr.
H. Kelly. - - - - 559
Extraordinary Obesity. - - 560
Exsection of the Head of the Hu-
merus. By Prof. Geo. C. Black-
man. 560

Gelseminum Sempervirens in Go-
norrhoea. By Dr. John Doug-
las. 560

Preservation of Vaccine Matter

by Solution in Glycerine. - 561
Woman with four Mammae. - 561
Philadelphia Hospital, Blockley. 561

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR OCTOBER 1 8 57.

Art. I. — On the Constitution and Physiology of the Bile. By Jno. C.
Dalton, Jr., M. D., Professor of Physiology and Microscopic Anatomy
in the College of Physicians and Surgeons, New York. (With seven wood-
cuts.)

Notwithstanding the readiness with which the bile may be obtained for
purposes of examination, the evident importance of the secretion, and the
labor which has been bestowed upon it, it must be confessed that we are still
very far from having a complete idea of its nature and function as one of the
intestinal fluids. The present condition of our knowledge with regard to it,
may be briefly summed up as follows : Since the analyses of Strecker, pub-
lished in 1848 and '49, it has been known that the bile contains, as its
essential and characteristic ingredients, two saline substances, the glykocholate
and the taurocholate of soda ; and that the organic acids of these salts, gly-
kocholic and taurocholic acid, both contain nitrogen ; and the latter, in
addition to it, two equivalents of sulphur. Besides these peculiar or charac-
teristic ingredients, the bile contains water, a colouring matter (biliverdin),
cholesterin, saponifiable and saponified fats, chloride of sodium, earthy and
alkaline phosphates, carbonates of soda and potass, and a variable quantity of
mucus.

The biliary fluid, thus constituted, was for a long time regarded by many
as a simple excretion, like the urine ; taking no part in digestion, and destined
merely to be expelled from the body. It could not, indeed, be shown to
exert any such digestive influence on the alimentary substances, as belonged
to the gastric and pancreatic juices; and its loss, when excluded from the
alimentary canal, did not give rise to any very marked disturbance, certainly
not to a suspension, of the digestive process. But the experiments of Bidder
and Schmidt1 seem to have demonstrated conclusively that its presence in

1 Verdauungssaefte und Stoffwechsel. Leipzig, 1852.

No. LXVIIL— Oct. 1857. 21

306

Dalton, Constitution and Physiology of Bile.

[Oct.

the alimentary canal is nevertheless essential to the continuance of life ; since
animals in which the whole of it is drawn off by a biliary fistula, though they
still feed and digest well, die after a few weeks, reduced to the last degree of
debility and emaciation. What the changes are, however, which it under-
goes in the intestine, or in what way it is made subservient to the nutritive
functions, has never been definitely ascertained.

Bidder and Schmidt have suggested that the organic acids of the biliary salts
were probably decomposed in the intestine, as they may be by boiling with caus-
tic potass in a test tube; giving as the result glycine in the one case, and taurine
in the other. But neither of these latter substances has ever been actually
found in the intestine. Liebig again suggested that the bile, or at least its
essential ingredients, might be reabsorbed from the alimentary canal, to
undergo further modifications elsewhere ; and Bidder and Schmidt have
shown (op. cit.) that the feces of the dog do not contain sulphur enough to
account for all the (sulphurous) taurocholic acid which is discharged daily
with the bile into the intestine. These facts render it exceedingly probable,
if not certain, that the bile is actually reabsorbed, under some form or other,
from the alimentary canal ; but further than that, there is little or nothing
definite, with regard to its physiology, to satisfy the mind of the inquirer.
All experimenters, who have undertaken the study of this secretion, have
found it the most difficult of investigation of all the intestinal fluids ; and yet
its importance is so palpable, and its occurrence in different species, orders
and classes of animals so universal, that it claims, and must continue to
receive the special attention of the physiologist.

Within the past two years we have endeavoured to clear up, so far as pos-
sible, some of the more obscure points with regard to the history of the bile,
and to obtain somewhat more satisfactory notions with regard to its properties
and function. The statements which are made in the following pages are
derived from the results of sixty-seven different experiments, many of which
comprised a series of secondary examinations, and occupied one or two days
in their performance. We have examined more particularly the special con-
stitution of the bile in different animals, the best mode of detecting it in
intestinal or other fluids, the quantity and time of its discharge into the
intestine, its reaction with the gastric and intestinal juices, and lastly its mode
of disappearance in the alimentary canal.

Constitution and Chemical Properties of the Bile. — The essential ingredients
of ox-bile are, as we have mentioned above, two peculiar saline substances,
the glykocholate and the taurocholate of soda. They may be obtained in the
following manner : The bile is first evaporated to dryness by the water bath.
The dry residue is then pulverized and treated with absolute alcohol, in the
proportion of at least 3j of alcohol to every five grains of dry residue. The
filtered alcoholic solution has a clear, yellowish colour. It contains, beside the
glykocholate and taurocholate of soda, the colouring matter and more or less
of the fats originally present in the bile. On the addition of a small quan-

1857.]

Dal ton, Constitution and Physiology of Bile.

307

tity of ether, a dense, whitish precipitate is formed, which disappears again
on agitating and thoroughly mixing the fluids. On the repeated addition of
ether, the precipitate again falls down, and when the ether has been added in
considerable excess, six to twelve times the volume of the alcoholic solution,
the precipitate remains permanent, and the whole mixture is filled with a
dense, whitish, opaque deposit, consisting of the glykocholate and taurocholate
of soda, thrown down under the form of heavy flakes and granules, part of
which subside to the bottom of the test tube, while part remain for a time in
suspension. Gradually these flakes and granules unite with each other and
fuse together into clear, brownish-yellow, oily, or resinous- looking drops. At
the bottom of the test-tube, after two or three hours, there is usually collected
a nearly homogeneous layer of this deposit, while the remainder continues to
adhere to the sides of the glass in small, circular, transparent drops. The
deposit is semi-fluid in consistency, and sticky, like Canada balsam or half-
melted resin ; and it is on this account that the ingredients composing it have
been called the " resinous matters" of the bile. They have, however, no real
chemical relation with true resinous bodies, since they both contain nitrogen,
and differ from resins also in other important particulars.

At the end of twelve to twenty-four hours the glykocholate of soda begins
to crystallize. The crystals radiate from various points in the resinous deposit,
and shoot up into the supernatant fluid in white silky bundles (Fig. 1). If

Fig. 1. Fig. 2.

Fig. 1. Ox-bile, extracted with, absolute alcohol and precipitated with ether-
Fig. 2. Glykocholate of soda, from ox-bile; after two days' crystallization. At the lower part of

the figure the crystals are melting into drops, from the evaporation of the ether and absorption of

moisture.

some of these crystals be removed and examined by the microscope, they are
found to be of a very delicate acicular form, running to a finely-pointed ex-

308

Dalton, Constitution and Physiology of Bile.

[Oct.

tremity, and radiating, as already mentioned, in bundles from a central point
(Fig. 2). As the ether evaporates, the crystals absorb moisture from the
air, and melt up rapidly into clear resinous drops \ so that it is very difficult
to keep them under the microscope long enough for a correct drawing and
measurement.

The crystallization in the test tube goes on after the first day, and the crys-
tals increase in quantity for three or four, and even five or six days, until the

whole of the glykocholate of soda
3* present has assumed the solid

form. The taurocholate, how-
ever, is uncrystallizable, and re-
mains in an amorphous condition.
If a portion of the deposit be now
removed and examined by the
microscope, it is seen that the
crystals of glykocholate of soda
have increased considerably in
thickness (Fig. 3), so that their
transverse diameter may be readi-
timated. The uncrystalliz-
able taurocholate appears under
the form of circular drops, vary-
ing considerably in size, clear,
Glykocholate and taurocholate of soda, from ox- transparent, strongly refractive,

bile; after six days' crystallization. The glykocho- ij -l ji

late is crystallized ; the taurocholate is in fluid drops. and bounded by a dark, well

defined outline. They are not to
oe distinguished, by any of their optical properties, from oil globules as they
usually appear under the microscope. They have the same refractive power,
the same dark outline and bright centre, and the same degree of consistency.
They would be consequently liable at all times to be mistaken for oil globules,
were it not for the complete dissimilarity of their chemical properties.

Both the glykocholate and taurocholate of soda are very freely soluble in
water. If the mixture of alcohol and ether be poured off and distilled water
added, the deposit dissolves rapidly and completely with a more or less dis-
tinct yellowish colour, according to the proportion of colouring matter ori-
ginally present in the bile. The two biliary substances present in the solution
may be separated from each other by the following means. On the addition
of acetate of lead, the glykocholate of soda is decomposed, and precipitates
as a glykocholate of lead. The precipitate, separated by filtration from the
remaining fluid, is then decomposed in turn by carbonate of soda, and the ori-
ginal glykocholate of soda reproduced. The filtered fluid which remains, and
which contains the taurocholate of soda, is then treated with subacetate of
lead, which precipitates a taurocholate of lead. This is separated by filtration,
and decomposed again by carbonate of soda, as in the former case. The two

1857.]

Dalton, Constitution and Physiology of Bile.

309

biliary substances in ox-bile may, therefore, be distinguished by their reactions
with the salts of lead. Both are precipitable by the subacetate; but the
glykocholate of soda is precipitable also by the acetate, while the taurocholate
is not so. If subacetate of lead, therefore, be added to the mixed watery
solution of the two substances, and the whole filtered, the subsequent addition
of acetate of lead to the filtered fluid will produce no precipitate, because both
the biliary matters have been entirely thrown down with the deposit; but, if
the acetate of lead be first added, it will precipitate the glykocholate alone,
and the taurocholate may afterwards be thrown down separately by the sub-
acetate.

The biliary substances, however, are not the same in different species of ani-
mals. In examining the biliary secretions of different species, Strecker found
so great a resemblance between them that he was disposed to regard their
ingredients as essentially the same. Having established the existence in ox-
bile of two peculiar substances, one crystallizable and non-sulphurous (glyko-
cholate), the other uncrystallizable and sulphurous (taurocholate), he was led
to consider the bile in all species of animals as containing the same substances,
and as differing only in the relative quantity in which the two were present.
The only exception to this was supposed to be pig's bile, in which Strecker
found a peculiar organic acid, which he called ff hyocholic," or " hyocholinic"
acid, in combination with soda as a base.

The above conclusion of his, however, was not entirely correct. The bile
of all animals, so far as examined, does, it is true, con-
tain peculiar substances which resemble each other in
being freely soluble in water, soluble in absolute alco-
hol, and insoluble in ether; and in giving also a pecu-
liar reaction with Pettenkofer's test, to be described
presently. But, at the same time, these substances
present minor differences in different animals, which
show them not to be identical.

In dog's bile, for example, there are, as in ox-bile,
two substances precipitable by ether from their alco-
holic solution ; one crystallizable, the other not so.
But the former of these crystallizes much more readily
than the glykocholate of soda from ox-bile. Dog's bile
will not unfrequently begin to crystallize freely in five
to six hours after precipitation by ether (Fig. 4);
while in ox-bile it is usually twelve and often twenty-
four and even forty-eight hours before crystallization
is fully established. But it is more particularly in
their reaction with the salts of lead that the difference
between these substances becomes manifest. For,
while the crystallizable substance of ox-bile is precipi-
tated by acetate of lead, that of dog's bile is not affected by it.

Fig. 4.

Dog's bile, extracted with
absolute alcohol and pre-
cipitated with ether.

If dog's bile

310

Dalton, Constitution and Physiology of Bile.

[Oct.

be evaporated to dryness, extracted with absolute alcohol, the alcoholic solu-
tion precipitated by ether, and the ether-precipitate then dissolved in water,
the addition of acetate of lead to the watery solution produces not the slightest
turbidity. If subacetate of lead be then added in excess, a copious precipitate
falls, composed of both the crystallizable and uncrystallizable substances. If
the lead-precipitate be then separated by filtration, washed, and decomposed
by carbonate of soda, the watery solution will contain the re-formed soda-salts
of the bile. The watery solution may then be evaporated to dryness, ex-
tracted with absolute alcohol, and the alcoholic solution precipitated by ether,
when the ether-precipitate crystallizes partially after a time as in fresh bile.
Both the biliary matters of dog's bile are therefore precipitable by subacetate
of lead, but neither of them by the acetate. Instead of calling them, conse-
quently, glykocholate and taurocholate of soda, we shall speak of them simply
as the " crystalline" and "resinous" biliary substances.

In cat's bile the biliary substances act very much as in dog's bile. The
ether-precipitate of the alcoholic solution contains here also a crystalline and
a resinous substance, both of which are soluble in water, and both precipitable
by the subacetate of lead ; but neither of them by the acetate.

In pig's bile, on the other hand, there is no crystallizable substance, but
the ether-precipitate is altogether resinous in appearance. Notwithstanding
this, however, its watery solution precipitates abundantly
5« by both the acetate and subacetate of lead.

In human bile, again, there is no crystallizable sub-
stance. We have found that the dried bile, extracted
with absolute alcohol, makes a clear, brandy-red solution,
which precipitates abundantly with ether in excess; but
the ether-precipitate, if allowed to stand, shows no sign
of crystallization, even at the end of three weeks (Fig. 5).
If the resinous precipitate be separated by decantation,
and dissolved in water, it precipitates, as in the case of
pig's bile, by both acetate and subacetate of lead. This
might, perhaps, be attributed to the presence of two dif-
ferent substances, as in ox-bile, one precipitated by the
acetate, the other by the subacetate of lead. Such, how-
ever, is not the case. For if the watery solution be pre-
cipitated by the acetate of lead and then filtered, the
filtered fluid gives no precipitate afterward by the sub-
acetate; and if first precipitated by the subacetate, it
Human bile, extract- gives 110 precipitate, after filtration, by the acetate,
ed with absolute aico- Different kinds of bile vary also in other respects,
tu'h ^hderprecipitated as, for example, their specific gravity, the depth and
tinge of colour, the quantity of fat which they con-
tain, *fcc. &c. Pig's bile is of a nearly clear yellow colour, human bile of
a dark golden brown, ox-bile of a greenish yellow, dog's bile of a deep

1857.] Dalton, Constitution and Physiology of Bile. 311

brown. The alcoholic solution of dried ox-bile does not precipitate at all on
the addition of water, while that of human bile, pig's bile, and dog's bile,
precipitates abundantly with distilled water, owing to the quantity of fat
which it holds in solution. We have found the specific gravity of pig's bile
to be 1030 to 1036; that of human bile 1018; that of ox-bile 1024. These
variations, however, are of secondary importance in comparison with those
which have been already mentioned, and which show that the crystalline and
resinous substances in different kinds of bile, though resembling each other
in very many respects, are yet in reality by no means identical.

Tests for Bile. — In investigating the physiology of any animal fluid, it is,
of course, of the first importance to have a convenient and reliable test by
which its presence may be detected. The only test which was for a long time
employed in the case of the bile was that which depended on a change of
colour produced by oxidizing substances. If the bile, for example, or a mix-
ture containing bile, be exposed in an open glass vessel for a few hours, the
upper layers of the fluid, which are in contact with the atmosphere, gradually
assume a greenish tinge, which becomes deeper with the length of time
which elapses, and the quantity of bile existing in the fluid. Nitric acid,
added to a mixture of bile and shaken up, produces a dense precipitate which
takes a bright grass-green hue. Tincture of iodine produces the same change
of colour, when added in small quantity; and probably there are various
other substances which would have the same effect. It is by this test that
the bile has so often been recognized in the urine, serous effusions, the solid
tissues, &c, in cases of jaundice. But it is a very insufficient one for any-
thing like accurate investigation, since the appearances are produced simply
by the action of an oxidizing agent on the colouring matter of the bile. A
green colour produced by nitric acid does not therefore indicate the presence
of the biliary substances proper, but only of the biliverdin. On the other
hand, if the colouring matter be absent, the biliary substances themselves
cannot be detected by it. For if the biliary substances of dog's bile be pre-
cipitated by ether from an alcoholic solution, dissolved in water and deco-
lorized by animal charcoal, the colourless watery solution gives no green
colour on the addition of nitric acid or tincture of iodine, though it precipi-
tates abundantly by subacetate of lead, and gives the other reactions of the
crystalline and resinous biliary matters in a perfectly distinct manner.

Pettenkofer' s lest. — This is undoubtedly the best test yet proposed for the
detection of the biliary substances. It consists in mixing with a watery so-
lution of the bile, or of the biliary substances, a little cane sugar, and then
adding sulphuric acid to the mixture until a red, lake, or purple colour is
produced. A solution may be made of cane sugar, in the proportion of one1
part sugar to four parts water, and kept for use. One drop of this solution
is mixed with the suspected fluid, and the sulphuric acid then immediately
added. On first dropping in the sulphuric acid a whitish precipitate falls,
which is abundant in the case of ox-bile, less so in that of the dog. This

312

Dalton, Constitution and Physiology of Bile.

[Oct.

precipitate redissolves in a slight excess of sulphuric acid, which should then
continue to be added until the mixture assumes a somewhat syrupy consist-
ency and an opalescent look, owing to the development of minute bubbles of
air. A red colour then begins to show itself at the bottom of the test tube,
where the drops of sulphuric acid accumulate, which disappears, however, on
agitating the mixture. On continuing the addition of sulphuric acid, the red
colour returns and becomes general, till the whole fluid is of a clear bright
cherry-red. This gradually changes to a lake colour, and finally to a deep,
rich, opaque purple. If three or four volumes of water be then added to
the mixture, a copious precipitate falls down, and the colour is destroyed.

Various circumstances modify to some extent the rapidity and distinctness
with which the above changes are produced. If the biliary substances be
present in large quantity, and nearly pure, the red colour shows itself at
once after adding an equal volume of sulphuric acid, and almost immediately
passes into a strong purple. If they be scanty, on the other hand, the red
colour may not show itself for seven or eight minutes, nor the purple under
twenty or twenty-five minutes. If foreign matters, again, not of a biliary
nature, be also present, they are apt to be acted upon by the sulphuric acid,
and by becoming discoloured interfere with the clearness and brilliancy of the
tinges produced. On this account it is indispensable, in delicate examina-
tions, to evaporate the suspected fluid to dryness, extract the dry residue with
absolute alcohol, precipitate the alcoholic solution with ether, and dissolve
the ether-precipitate in water before applying the test. In this manner all
foreign substances likely to do harm will be eliminated, and the test will suc-
ceed without difficulty.

It must not be forgotten, beside, that the sugar itself is liable to be acted
on and discoloured by sulphuric acid when added in excess, and may there-
fore by itself give rise to confusion. A little care and practice, however, will
enable the experimenter to avoid any chance of deception from this source.
When sulphuric acid is mixed with a watery solution containing cane sugar,
after it has been added in considerable excess, a yellowish colour begins to
show itself, owing to the commencing decomposition of the sugar. This
colour gradually deepens until it has become a dark, dingy, muddy brown;
but there is never at any time clear red or purple colour unless biliary matters
be present. If the bile be present in small quantity the colours produced by
it may be modified and obscured by the dingy yellow and brown of the
sugar; but even this difficulty may be avoided by paying attention to the
following precautions. In the first place, only very little sugar should be
added to the suspected fluid. In the second place, the sulphuric acid should
be added very gradually, and the mixture closely watched to detect the first
changes of colour* If bile be present, the red colour peculiar to it is always
produced before the yellowish tinge which indicates the decomposition of the
sugar. When the biliary matters, therefore, are present in small quantity,
the addition of sulphuric acid should be stopped at that point, and the

1857.]

Dalton, Constitution and Physiology of Bile.

313

colours, though faint, will then remain clear, and give unmistakable evidence
of the presence of bile.

The red colour alone is not sufficient as an indication of bile. It is, in fact,
only the commencement of the change which indicates the biliary matters. If
these matters be present, the colour passes, as we have already mentioned,
first into a lake, then into a purple; and it is this lake and purple colour
alone which can be regarded as really characteristic of the biliary reaction.

Pettenkofer has given directions, as quoted by Lehmann, that the elevation
of temperature in this experiment, naturally produced by mixing sulphuric
acid and water, should not be allowed to exceed 120° F. This, however, is
not by any means indispensable. We have often found the lake and purple
colours to be produced with the greatest intensity, without taking any pre-
caution to keep down the temperature, and while the test-tube was still very
hot. Used in this way, Pettenkofer's test may be regarded as of very valua-
ble assistance in the detection of the bile. Its reaction takes place with the
bile of all the different species of animals, so far as examined, and with a
nearly uniform degree of intensity. It is much more certain and charac-
teristic, therefore, than the test by nitric acid, or tincture of iodine.

Pettenkofer 's reaction is produced by the presence of both, or either of the
two biliary substances, crystalline or resinous, and is not dependent on the
colouring matter of the bile.

1. The bile is evaporated to dryness, the dry residue extracted by absolute
alcohol, and the alcoholic solution precipitated by ether. The mixture is
then allowed to stand until the crystalline and resinous substances have both
completely separated. The mixed alcohol and ether are then poured off, and
the precipitate dissolved in distilled water and decolorized. The watery,
solution now gives Pettenkofer's reaction perfectly, though, as previously
mentioned, it does not produce any green colour with nitric acid and a tinc-
ture of iodine.

2. The ether-precipitate of the alcoholic solution of dried ox-bile is dissolved
in distilled water. The glykocholate of soda is then precipitated from its
watery solution by acetate of lead, separated by filtration, washed, re-composed
by carbonate of soda, and again dissolved in water. The remainder of the
filtered fluid is then precipitated by subacetate of lead, and the precipitate
treated as before with carbonate of soda, and dissolved. The two watery
solutions, one containing the glykocholate, the other the taurocholate of soda,
both give Pettenkofer's reaction decisively and completely.

Various objections have been urged against this test. It has been stated
to be uncertain and variable in its action. Eobin and Yerdeil ( Chimie Ana-
tomique et Physiologxque), say that its reactions "do not belong exclusively
to the bile, and may therefore give rise to mistakes." Some fatty substances
and volatile oils (olein, oleic acid, oil of turpentine, oil of caraway) have
been stated to produce similar red and violet colors when treated with sugar
and sulphuric acid. These objections, however, have not much, if any, prao-

314 Dal ton, Constitution and Physiology of Bile. [Oct.

tical weight. The test no doubt requires some care and practice in its appli-
cation, as we have already pointed out ; but that is the case, to a greater or
less extent, with nearly all chemical tests, particularly those for organic
substances. No other substance is liable to be met with in the intestinal
fluids or the blood, which would simulate the reactions of the biliary matters.
We have found that the fatty matters of the chyle, taken from the thoracic
duct, when tried with Pettenkofer's test, do not give any coloration which
would be mistaken for that of the bile. When the volatile oils (caraway and
turpentine) are acted on by sulphuric acid, a red colour is produced, which
afterwards becomes brown and blackish, and a peculiar, tarry, empyreumatic
odour is developed at the same time ; but we do not get the lake and purple
colours spoken of as above. Finally, if the precaution be observed of first
extracting the suspected matters with absolute alcohol, then precipitating with
ether, and dissolving the precipitate in water, no ambiguity could result from
the presence of any of the above substances. The imperfection of the test
does not, in fact, consist in its liability to cause other substances to be mis-
taken for the biliary matters, but in failing sometimes to detect small quan-
tities of the latter when they are really present.
Pettenkofer's test is not a very delicate one.

If two drops of dog's bile be added to 3j of distilled water, and the mixture
tried with Pettenkofer's test, it becomes deep cherry red in half a minute,
lake in one minute, and a distinct opaque purple in four minutes.

One drop of dog's bile mixed with 3j distilled water, tried by the same
test, becomes cherry red in two minutes and a half, and lake in four minutes;
but there is no purple colour, even at the end of an hour.

One-half a drop of dog's bile with 3j distilled water, becomes, on the
application of Pettenkofer's test, of a somewhat dingy cherry red within a
minute ; but there is no lake or purple at the end of an hour.

One quarter of a drop of dog's bile with Jj distilled water, on the addition
of sugar and sulphuric acid, becomes immediately yellowish ; but afterward
only "turns of a dingy yellowish brown, hardly, if at all, distinguishable from
that produced with a simple solution of cane sugar in water.

Pettenkofer's test, therefore, cannot be relied on for the detection of very
minute quantities of the biliary substances. Still it is the best we have, and
an admirable one so far as it goes. All chemical tests are limited in this
way, with respect to the delicacy of their application. Even Trommer's test
for sugar acts very imperfectly with a solution of one-sixteenth of a drop of
honey to the drachm of water ; and with a solution of one-thirty-second of a
drop to the drachm, fails altogether to detect the presence of sugar. Petten-
kofer's test, then, if used with care, is extremely useful, and may lead to
many valuable results.

With regard to the physiology of the bile, one of the first points which we
have endeavoured to examine, is the following : At what period, and how
constantly, is the bile discharged into the intestinal canal? The experiments

1857.]

Dalton, Constitution and Physiology of Bile.

315

for this purpose were performed on dogs. The animals were kept confined,
and killed at various periods after feeding, sometimes by the inoculation of
woorara, sometimes by hydrocyanic acid, but most frequently by section of
the medulla oblongata. The contents of the intestine were then collected
and examined. In all instances the bile was also taken from the gall-bladder,
and treated in the same way with the contents of the intestine, for purposes
of comparison. The intestinal contents always presented some differences of
appearance when treated with alcohol and ether, owing, probably, to the
presence of other substances than the bile ; but they always gave evidence of
the presence of biliary matters as well. The biliary substances could almost
always be recognized under the
microscope in the ether-precipi-
tate of the alcoholic solution;
the resinous substance under the
form of rounded, oily-looking
drops, and the other under the
form of crystalline groups, gene-
rally presenting the appearance
of double bundles of slender,
radiating, slightly curved or
wavy needle-shaped crystals.
(Fig. 6.) These substances,
dissolved in water, gave a purple
colour with sugar and sulphuric
acid. These experiments were
tried after the animals had been
kept for one, two, three, five, six,
seven, eight, and twelve days

without food. The result showed that in all these instances bile was present
in the small intestine. It is plainly, therefore, not an intermittent secretion,
nor one which is concerned exclusively in the digestive process ; but, its
secretion is constant and it continues to be discharged into the intestine for
many days at least after the animal has been deprived of food.

The next point of importance to be examined relates to the time, after
feeding, at which the bile passes into the intestine in the greatest abundance.
Bidder and Schmidt {op. cit.) have already investigated this point in the
following manner. They operated by tying the common bile-duct and then
opening the fundus of the gall-bladder so as to produce a biliary fistula by
which the whole of the bile was drawn off. By doing this operation, and
collecting and weighing the fluid discharged at different periods, they came
to the conclusion that the flow of bile began to increase within two and a half
to three hours after the introduction of food into the stomach ; but that it
did not reach its maximum of activity till the end of twelve or fifteen hours.
Other observers, however, have obtained different results. Arnold, for ex-

Crystalline and resinous biliary substances;
small intestine of dog after two days' fasting.

from

316

Dalton, Constitution and Physiology of Bile.

[Oct.

ample (in Am. Journ. Med. Sci., April, 1856), found the quantity to be
largest soon after meals, decreasing again after the fourth hour. Kblliker
and Muller, again (in Am. Journ. Med. Sci., April, 1857), found it largest
between the sixth and eighth hours. Bidder and Schmidt's experiments, in-
deed, strictly speaking, show only the time at which the bile is most actively
secreted by the liver, but not when it is actually discharged into the intestine.
Our own experiments, bearing upon this point, were performed on dogs, by
making a permanent duodenal fistula on the same plan that gastric fistulas
have so often been established for the examination of the gastric juice
(Fig. 7). An incision was made through the abdominal walls, a short dis-
tance to the right of the median line, the floating portion of the duodenum

drawn up towards the external wound,
Fig. 7. opened by a longitudinal incision, and

a silver tube, armed at each end with
a narrow projecting collar or .flange,
introduced into it by one extremity,
five and a half inches below the pylo-
rus, and two and a half inches below
the orifice of the lower pancreatic
duct. The other extremity of the
tube was left projecting from the ex-
ternal opening in the abdominal pa-
rietes, the parts secured by sutures,
ill ^fel'^y \ and the wound allowed to heal. After

wft B| I \M cicatrization was complete, and the

k^Bl\ BE U cv animal had entirely recovered his

healthy condition and appetite, the
intestinal fluids were drawn off at va-
rious intervals after feeding, and their
contents examined. This operation,
which is rather more difficult than
that of making a permanent gastric
fistula, is nevertheless exceedingly
useful when it succeeds, since it en-
ables us to study not only the time
and rate of the biliary discharge, but
also many other extremely interesting
matters connected with intestinal digestion. Of five animals operated on,
we lost three, and succeeded in retaining a permanent fistula in two.

The results obtained from the experiments on these animals, may be sum-
marily stated as follov. s. Twenty-four hours after feeding there flows from
the fistula a small quantity of fluid, partly brownish and bilious-looking,
partly colourless, nearly clear, and more or less frothy. These fluids are
mostly neutral, or faintly alkaline, but sometimes have a slightly acid reac-

Duodenal fistula. a. Stomach, b. Duode-
num, c, c, e. Pancreas ; its two ducts are seen
opening into the duodenum, one near the orifice
of the biliary duct (d), the other a short distance
lower down. e. Silver tube, passiug through
the abdominal walls and opening into duo-
denum.

1857.] Dalton, Constitution and Physiology of Bile. 317

tion. They come in starts and gushes, sometimes mixed, but very frequently
alternating with each other. If the animal be then fed with a full meal (two
pounds) of fresh lean meat, during the first fifteen minutes afterward a large
quantity of nearly pure bile is poured into the intestine, mingled during the
latter part of the time with some gastric juice from the stomach, containing
a little albuminose in solution, which precipitates with the bile, forming an
opaque bright yellow mixture. This second fluid soon becomes more abund-
ant in proportion to the bile, precipitating a molecular sediment, and becoming
less and less strongly coloured. In half an hour to an hour, a fine debris of
broken-up muscular fibres begins to pass out of the stomach into the intestine
suspended in the gastric juice, forming a grayish, gruelly, fluid mixture, in
which the proportion of bile to the other ingredients gradually diminishes.
This continues from the second to about the twelfth hour, the proportion of
muscular debris growing constantly greater, and that of fluid less, so that the
mixture is considerably thicker, and more gruelly than at first. The entire
quantity of the mixture, also, grows pretty constantly less until the twelfth
hour. After that time, the mixture of muscular debris and gastric juice
ceases more or less promptly, and the bile becomes again more abundant in
proportion to the other ingredients. It is still mixed, however, with the in-
testinal fluids, and so continues till the end of the twenty-four hours.

In order to ascertain the absolute quantity of bile discharged into the in-
testine, and its variations during digestion, the duodenal fluids were drawn
off, for fifteen minutes at a time, at various periods after feeding, collected,
weighed, and examined separately, as follows : each separate quantity was
evaporated to dryness, its dry residue extracted with absolute alcohol, the
alcoholic solution precipitated with ether, and the ether-precipitate, regarded
as representing the amount of biliary matters present, dried, weighed, and
then treated with Pettenkofer's test in order to determine, as nearly as pos-
sible, their degree of purity or admixture. The result of these experiments
is given in the following table. At the eighteenth hour so small a quantity
of fluid was obtained that the amount of its biliary ingredients was not ascer-
tained. It reacted perfectly, however, with Pettenkofer's test, showing that
bile was really present.

Time

Quantity of

Dry residue
of same.

Quantity of

Proportion of

after feeding.

fluid in fifteen
minutes.

biliary mat-
ters.

biliary matters
to dry residue.

Immediately .

. 640 grs.

33 grs.

10 grs.

.30

1 hour

. 1,990 "

105 "

4 "

.03

3 hours .

. 780 "

60 "

4 "

.07

6 hours .

. 750 "

73 "

81 "

.05

9 hours .

. 860 «

78 "

4J «

.06

12 hours .

. 325 «

23 «

3f "

.16

15 hours .

. 347 "

18 "

4 "

.22

18 hours .

21 hours .

. 384 "

11 "

1 "

.09

21 hours .

. 163 »

H "

.34

25 hours .

. 151 "

5 »

3 "

.60

318

Dal ton, Constitution and Physiology of Bile.

[Oct.

From this it appears that the bile passes into the intestine in by far the
largest quantity immediately after feeding and within the first hour. After
that time its discharge remains pretty constant, not varying much from four
grains (solid biliary matters) every fifteen minutes, or sixteen grains per
hour. (This animal weighed 36 £ pounds.)

There is, however, an interval, from about the eighteenth to the twenty-
first hour, during which its quantity is much less, and the intestine appears
to be in a state of temporary inactivity. But though the absolute quantity
of bile remains, with this exception, nearly uniform within the above period,
its relative quantity to that of the other ingredients increases pretty con-
stantly after the first hour, owing to the diminishing proportion of the
digestive fluids and of the alimentary matters which are undergoing solution.

These facts lead us to the consideration of another question which is of
great interest in this connection, viz., what part, if any, does the bile take in
digestion ? We have seen that not only its secretion, but also its discharge
into the intestine, are both nearly constant, even after the animal has been
many days without food; and consequently that it cannot have, like the
gastric and pancreatic juices, an exclusive relation to the digestive process.
Still, it is actually present also in the intestine during digestion ; and is even
discharged into it most abundantly immediately after the introduction of food
into the stomach, and before the mixture of gastric juice and half-digested
food has begun to pass through the pylorus into the intestine. Is this merely
a coincidence, or does it have some definite relation to the changes which the
food or the bile or both are to undergo in the alimentary canal ? With regard
to this question the following facts are of some interest.

The bile precipitates with the gastric juice.

This precipitation can be readily seen in the fluids drawn from the duo-
denal fistula, half an hour or more after feeding ; when the fluids come, as
mentioned above, in intermitting starts and gushes, sometimes neutral or
alkaline, clear, and brownish, like nearly pure bile, then as a bright, yellowish,
turbid mixture, then nearly colourless and acid, consisting mostly of gastric
juice with muscular debris. It can also be seen by mixing in a test tube
gastric juice from the dog, obtained by means of a gastric fistula, with bile
from the gall-bladder of the same animal. If four drops of bile be added in
this way to 3j of gastric juice, a precipitate falls which contains the whole of
the colouring matter of the bile ) and if the mixture be then filtered, the
filtered fluid passes through quite colourless, and is no longer turned green
by nitric acid. The gastric juice, notwithstanding this precipitation, retains
its acid reaction, but at the same time loses its power of dissolving albumi-
nous substances. For, if gastric juice which has been precipitated in the
above manner be filtered, and then kept in a test tube at the temperature of
100° F. with a piece of boiled white of egg, the white of egg becomes some-
what more transparent and brittle and grows contracted and cracked, but the
gastric juice exerts little or no dissolving action upon it. This reaction of

1857 ] Dalton, Constitution and Physiology of Bile. 319

the bile and gastric juice deserves a closer examination, since the two fluids
certainly do mix in the intestine, and must exert a more or less important
action on each other.

It is the biliary substances themselves which cause the precipitation with
gastric juice.

If the crystalline and resinous substances of dog's bile be separated from
the other ingredients by the process already several times described, and after
precipitation by ether dissolved in distilled water, they make a clear, colour-
less solution. Such a solution, made in the proportion of three grains biliary
matters to 3j of water, precipitates with gastric juice like the bile from the
gall-bladder; only the precipitate in this instance is colourless. When fresh
bile, therefore, is used, the colouring matter is merely entangled and thrown
down with some other substance ; the precipitate takes place, however, with
the biliary matters proper just as well when the colouring matter is absent.

But the biliary substances themselves are not precipitated; for if 3j of
filtered gastric juice, taken from the stomach six hours after feeding, be pre-
cipitated by the addition of four drops, two drops, or even one drop of bile
from the gall-bladder, and the turbid mixture filtered, the clear filtered fluid
in every instance gives abundant evidence of the presence of biliary matters
by Pettenkofer's test. The biliary substances, therefore, or at least by far the
greater part of them, remain in solution and do not fall down with the pre-
cipitate by gastric juice.

This reaction of the biliary and gastric fluids, though very important in
respect to the theory of intestinal digestion, does not appear to have any
particular bearing on the subsequent history of the bile itself. It is the
gastric juice and the alimentary substances which are affected by coming in
contact with the bile, not the biliary ingredients themselves. The effect of
this precipitation, however, on the gastric juice and food, even, is not very
thoroughly understood. " It has been thought by Bernard that the contact of
the bile stops altogether the digestive action of the gastric juice, precipitating
at the same time all the albuminose which it had previously dissolved \ this
precipitated albuminose being afterward dissolved by the action of the pan-
creatic juice, which is regarded by M. Bernard as an exceedingly active
agent in intestinal digestion. Some facts which have been mentioned above,
seem, indeed, to support this opinion ; as, for example, that the gastric juice,
when precipitated with bile, loses its power of artificially dissolving boiled
white of egg in a test tube. But it very soon becomes evident to the experi-
menter that these artificial digestions do not always represent exactly the
process as it takes place in the living animal. They may be of great service
in suggesting and directing subsequent examinations, but can rarely be
depended on exclusively as settling any given question. The gastric fluids,
taken from the stomach some time after feeding and filtered, often contain
organic matter in solution under a different form from that which it assumes
when the digestion is conducted artificially in test tubes. We have found, in

320 Dalton, Constitution and Physiology of Bile. [Oct.

point of fact, that bile from the dog's gall-bladder always precipitates with
the gastric juice as it passes from the stomach into the intestine, whether it
be taken from the stomach fifteen minutes, half an hour, or six hours after
feeding. The acid fluids drawn from the duodenal fistula, also, three and six
hours after feeding, will precipitate with those drawn twenty to twenty-five
minutes after feeding, and in which the proportion of biliary matters is larger.

But there are some considerations which militate against the simple view
of intestinal digestion entertained by M. Bernard. In the first place the gastric
fluids precipitate with the pancreatic juice as well as with the bile, when mixed
in a test tube; while the two intestinal fluids, bile and pancreatic juice, do
not precipitate with each other. In the second place, it is a remarkable
fact that bile very constantly finds its way into the stomach, in larger or
smaller quantities, at almost all periods of digestion. This fact has already
been noticed by Lehmann, who states (Physiological Chemistry, Philad. ed.,
vol. i. p. 447) that he has "made few examinations of human bodies, or even
of recently killed healthy animals, in which he has not discovered biliary con-
stituents in the contents of the stomach lying near the pyloric end." In the
pig it is almost universal to find the pyloric portion of the gastric mucous
membrane after death permanently stained of a bright yellow by bile. It is
very common indeed, furthermore, while drawing off the fluids of the stomach
by a gastric fistula within the first fifteen minutes after feeding, to see bile
suddenly make its appearance, evidently by regurgitating through the pylorus,
when the clear, colourless gastric juice instantly becomes turbid and yellowish.
In a few moments the bile may cease to present itself, and the gastric fluids
regain their colourless and transparent appearance, to be again, perhaps, ren-
dered turbid and yellow some moments afterward. The gastric fluids, even,
which are drawn six hours after feeding, and which are thick, grayish and
gruelly in appearance, if filtered clear, will frequently give distinct evidence
of the presence of bile by Pettenkofer's test. All this certainly does not essen-
tially interfere with the process of gastric digestion ; and the action of the
bile on the digested food in the intestine evidently does not correspond exactly
with any explanation which has been suggested.

The next series of experiments to which we resorted were undertaken in
order to investigate, so far as possible, the following very obscure question,
viz : What becomes of the bile in its passage through the intestine? The dogs
used for these experiments were fed with fresh meat and then killed at va-
rious intervals after the meals, the abdomen opened, ligatures placed upon the
intestines at different points, and the contents of their upper, middle and
lower portions collected and examined separately. The results thus obtained
show that, under ordinary circumstances, the bile, which is quite abundant in
the duodenum and upper part of the small intestine, diminishes in quantity
from above downward, and is not to be found in the large intestine. The
entire quantity of the intestinal contents diminishes and their consistency
increases as we approach the ileo-caccal valve. At the same time their colour

1857.]

Dalton, Constitution and Physiology of Bile.

321

changes from a light yellow to a dark bronze, or blackish green, which is
always strongly pronounced in the last quarter of the small intestine. The
following experiment will serve to show the plan which was followed and its
results.

Experiment. — A full-grown, healthy bitch, was fed with fresh meat, then
kept entirely without food, but supplied only with water, for five days. At
the end of that time she was killed by section of the medulla.

The stomach contained fl^ss of a nearly colourless, dingy, frothy, neutral
fluid.

Upper half of small intestine contained 117 grains of a dull yellow, gelati-
nous, semi-fluid, neutral matter. Its dry residue was 24 grains.

Lower half of small intestine contained 130 grains of a much darker
bronze-coloured neutral gelatinous mass, a large proportion of which consisted
of hairs and intestinal worms, which were not present in the contents of upper
half. Dry residue 20 grains.

Large intestine contained 210 grains of a dark, olive-brown, consistent
mass, slightly acid in reaction. Dry residue 73 grains.

All three lots were then evaporated to dryness, and afterward exhausted
by repeated extraction with absolute alcohol, until the filtered alcohol came
through perfectly colourless, and no longer gave any turbidity with ether.
The alcoholic solutions were then reduced by evaporation to the same volume
and precipitated with ether in excess. The ether-precipitate was separated,
dried under the air-pump, and weighed. The results obtained in this way are
given in the two following tables : —

Table 1.

Weight of Dry residue Ether-pre- Proportion of

fresh contents, of same. cipitate. ether-precip. to

r fresh contents.

Upper half of small intestine 117 grains. 24 grains. 5 grains. .0427

Lower " " 130 " 20 " 5 " .0384

Large intestine . . .210 " 73 « 3 » .0142

Table 2.

, Weight of solid Ether-pre- Proportion of ether-precip.

residue. cipitate. to solid residue.

Entire small intestine . . 44 grains. 10 grains. .227

Large intestine .... 73 " 3 " .041

The ether-precipitate of the alcoholic solution is, therefore, both positively
and relatively very much less in the large intestine than in the small. Its
proportion to the entire solid contents is only one-fifth or one-sixth as great in
the large as it is in the small intestine. But even this small quantity does
not consist of biliary matters ; for the dried ether precipitates, in the above
experiment, when dissolved in distilled water all three precipitated by sub-
acetate of lead; but that from the large intestine very much the least. The
watery solutions being treated with sugar and sulphuric acid, those from both
portions of the small intestine gave Pettenkofer's reaction promptly and per-
fectly in less than a minute and a half ; while in that from the large intestine
"No. LXVIIL— Oct. 1857. 22

322

Dalton, Constitution and Physioloyy of Bile.

[Oct.

no red or purple colour was produced even at the end of three hours, but only
a dingy, muddy brown.

The small intestine, consequently, contains at all times substances giving all
the reactions of the biliary ingredients; while in the contents of the large
intestine no such substances can be recognized by Pettenkofer's test.

The biliary matters, therefore, disappear in their passage through the in-
testine. This disappearance may be explained in two different ways. First,
the biliary matters may be actually reabsorbed from the intestine, and taken
up by the bloodvessels; or second, they may become so altered and decom-
posed by the intestinal fluids as to lose the power of giving Pettenkofer's re-
action with sugar and sulphuric acid, and pass off with the feces in an in-
soluble form. The first of these explanations is that which has recently been
regarded with the most favour ; and it is, in fact, rendered extremely probable
by the experiments of Bidder and Schmidt, already referred to, in which they
found that the entire quantity of sulphur contained in the feces of the dog
during five days was very much less than that which must have been dis-
charged with the bile into the intestine during the same time. It is almost
impossible to avoid the conclusion that it has been reabsorbed by the blood-
vessels. Still this gives us no idea how far the bile is altered before its
reabsorption ; and the direct and absolute proof, also, of finding the biliary
matters in the blood of the portal vein is still wanting. We have endea-
voured to supply the latter deficiency by examining the portal blood in dogs,
killed at various times after feeding. The animals were killed by section of
the medulla oblongata, a ligature immediately placed on the portal vein,
while the circulation was still active, and the requisite quantity of blood col-
lected. The blood was sometimes immediately evaporated to dryness by the
water bath. Sometimes it was coagulated by boiling in a porcelain capsule
over a spirit lamp, with water and an excess of sulphate of soda, and the .
filtered watery solution afterward examined. But most frequently, the blood,
after being collected from the vein, was coagulated by the gradual addition of
three times its volume of alcohol at ninety-five per cent., stirring the mixture
constantly, so as to make the coagulation gradual and uniform. It was then
filtered, the moist mass remaining on the filter subjected to strong pressure
in a linen bag by a porcelain press, and the fluid thus obtained added to that
previously filtered. The entire spirituous solution was then evaporated to dry-
ness, the dry residue extracted with absolute alcohol, and the alcoholic solution
treated as usual to discover the presence of biliary matters. In every instance
blood was taken at the same time from the jugulars or the abdominal vena cava,
and treated in the same way for purpose of comparison. We have examined
the blood in this way one, four, six, nine, eleven and a half, twelve and
twenty hours after feeding. As the result of these examinations it was found
that in the venous blood, both of the portal vein and of the general circula-
tion, there exists a substance soluble in water and absolute alcohol, and pre-
cipitable by ether from its alcoholic solution. This substance is often con-
siderably more abundant in the portal blood than in that from the general

1857.]

Dalton, Constitution and Physiology of Bile.

323

system. It adheres closely to the sides of the glass after precipitation, so
that it is always difficult and often impossible to obtain enough of it mixed
with ether for microscopic examination. It dissolves also, like the biliary
substances, with great readiness in water ; but in no instance have we ever
been able to obtain from it such a satisfactory reaction with Pettenkofer's
test, as would indicate the presence of bile. This is not because the reaction
is masked, as might be suspected, by some of the other ingredients of the
blood; for if at the same time two drops of bile be added to half an ounce
of blood taken from the abdominal vena cava, and the two specimens treated
alike, the ether precipitate may be considerably most abundant in the case of
the portal blood-; and yet that from the blood of the vena cava, dissolved in
water, will give Pettenkofer's reaction for bile perfectly, while that of the
portal blood will give no such reaction. Notwithstanding, then, the strong
probability that the biliary matters are taken up by the portal blood, we have
failed to recognize them there by Pettenkofer's test.

From the facts; therefore, which have been detailed above, we may derive
the following conclusions : —

I. The two biliary substances, crystalline and resinous, are not the same in
different species of animals, though they resemble each other in most of their
chemical properties.

II. In all cases, they act in the same way with Pettenkofer's test, whether
both or only one of them be present.

III. In different kinds of bile, the biliary matters are to be distinguished
from each other principally by their reaction with the salts of lead.

IV. In human bile there is no crystallizable biliary substance, but only a
resinous one. The same thing is the case with the bile of the pig.

V. Pettenkofer's reaction is the only available test for the biliary sub-
stances proper. It may fail to detect them when present in very small quan-
tity; but, if used with care, will not lead us to mistake other substances for
them.

VI. The bile in the carnivorous animals passes into the intestine for at
least twelve days after the last meal.

VII. It is discharged into the intestine most abundantly immediately after
feeding; during the remainder of the twenty- four hours its flow is about uni-
form (sixteen grains biliary matters per hour in a medium sized dog), except
from about the eighteenth to the twenty-first hour, during which time it is
much less.

VIII. When the bile comes in contact with the gastric fluids, the organic
matters of the latter are precipitated; but the biliary substances remain in
solution.

IX. The biliary substances disappear during their passage through the in-
testine, so that they can no longer be recognized by Pettenkofer's test.

X. They are, in all probability, reabsorbed into the blood ; but if so, they
first undergo in the intestine such changes, that they no longer give Petten-
kofer's reaction with sugar and sulphuric acid.

324

Hamilton; Compound Dislocation of the Long Bones.

[Oct.

Art. II. — Compound Dislocation of the Long Bones ; considered with Especial
Reference to the Value of Resection. By Frank Hastings Hamilton,
M. D., Prof, of Surgery in the Med. Dep. University of Buffalo.

Frequency of Compound as compared with Simple Dislocations. — Com-
pound dislocations, as compared with simple, are of rare occurrence. Of
ninety-four dislocations reported by Norris as having been received into the
Pennsylvania Hospital for the ten years ending in 1840, only two were com-
pound ;4 and of one hundred and sixty-six dislocations recorded in my obser-
vations, only eight were compound.3

Relative Frequency in the Different Joints.— -In my own recorded cases,
four were dislocations of the tibia inward at the ankle-joint, one was a
partial (pathological) luxation forward at the same joint, one was a luxation
of the astragalus, one a luxation of the head of the humerus into the axilla,
and one a forward luxation of the radius and ulna at the wrist-joint. Both
of the cases reported by Norris were dislocations of the thumb.

Sir Astley Cooper, speaking upon this point,3 says that the elbow, wrist,
ankle, and finger-joints are most subject to these accidents; and that he has
seen but two in the shoulder-joint, and one in the knee-joint. He had never
seen a compound dislocation at the hip-joint, and he believed that it was
" scarcely ever" so dislocated. On p. 119, however, Mr. Bransby Cooper
has reported in detail a very interesting case of this accident, communicated
to him by Dr. Walker, of Charlestown, Mass., in which reduction was ac-
complished by manipulation alone, by Dr. Ingalls, on the second day. The
patient died at the end of about three weeks. So far as I know, this is the
only case upon record. Malgaigne says that a compound dislocation at the
hip- joint has probably never occurred.4

Among the cases of compound dislocation recorded by Sir Astley and
Bransby Cooper, most of which were communicated to these gentlemen by
other surgeons, 45 were dislocations of the ankle, 10 of the astragalus, 4 of
the ulna at the wrist-joint, 4 of the thumb, 2 of the knee, 1 of the shoulder,
1 of the elbow, 1 of the radius and ulna at the wrist, 1 of the scaphoid bone,
and 1 of the metatarsal bone of the great toe. Other writers have occasion-
ally described compound dislocations of the clavicle, but I know of no record
of a compound dislocation of the lower jaw.

1 See this Journal, vol. xxvii. p. 335 (1841).

2 For the most of these cases, see Transactions of the New York State Med. Soc.
for 1855; article entitle! " Report on Dislocations, with Especial Reference to their
Results." By Frank H. Hamilton.

3 Treatise on Disloc, &c, Amer. ed., 1851, p. 59.

4 Traite des Frac. et des Lux., torn. ii. p. 212.

1857.] Hamilton, Compound Dislocation of the Long Bones.

325

Prognosis, as determined by the Mode of Treatment adopted by most of
the Ancient and many of the Modern Surgeons. — By most of the early
writers these accidents, whenever they occurred in the larger joints, were
regarded as nearly beyond the reach of art. Says Hippocrates : —

"In cases of complete dislocation at the ankle-joint, complicated with an
external wound, whether the displacement be inwards or outwards, you are
not to reduce the parts, but let any other physician reduce them if he choose.
For this you should know for certain, that the patient will die if the parts are
allowed to remain reduced, and that he will not survive more than a few days,
for few of them pass the seventh day, being cut off by convulsions, and some-
times the leg and foot are seized with gangrene." — Works of Hippocrates, pub-
lished by the Sydenham Soc, London, vol. ii. p. 634. Hippocrates adds, "But
if not reduced, nor any attempts at first made to reduce them, most of such
cases recover/'— Op. cit., p. 634.

The same remarks are applied by Hippocrates to compound dislocations of
the head of the tibia, of the lower end of the femur, of the wrist, elbow,
and shoulder-joints; death occurring in all cases, as he believes, more or less
speedily whenever the bones are reduced and retained in place a sufficient
length of time, and "were it not that the physician would be exposed to
censure" (op. cit., p. 638), he would not reduce even the bones of the fingers,
since it must be expected, he thinks, that, their articular extremities will
exfoliate even when the reduction is most successful.

I shall presently show, however, that even Hippocrates advised and probably
practised resection in certain cases of these accidents.

Both Celsus and Galen adopt almost without qualification the line of prac-
tice laid down by Hippocrates, and affirm equally the danger and almost cer-
tain death consequent upon the reduction of compound dislocations in large
joints.1 Celsus recommends resection in some cases.

Paulus iEgineta, however, and after him Albucasis, Haly Abbas and
Bhazes, do not regard the rules established by Hippocrates in relation to the
non-reduction of the bones as so imperative, nor the results of the opposite
practice as so uniformly fatal.

" Hippocrates remarks," says Paulus iEgineta, " in the case of dislocations
with a wound the utmost discretion is required. For these, if reduced, occa-
sion the most imminent danger, and sometimes death, the surrounding nerves
and muscles being inflamed by the extension, so that strong pains, spasms,
and acute fevers are produced more particularly in the case of the elbows,
knees and joints above, for the nearer they are to the vital parts the greater is
the danger they induce. Wherefore, Hippocrates, by all means, forbids us to
apply reduction and strong bandaging to them, and directs us to use only
anti-inflammatory and soothing applications to them at the commencement,
for that by this treatment life may sometimes be preserved. But what he
recommends for the fingers alone we would attempt to do for all the other
joints ; at first, and while the parts remain free from inflammation, we would
reduce the dislocated joint by moderate extension, and if we succeed in our
object we may persist in using the anti-inflammatory treatment only. But if
inflammation, spasm, or any of the afore-mentioned symptoms come on, we
must dislocate it again if it can be done without violence. If, however, we

1 Paulus ^gineta, vol. ii. p. 510, Syd. ed.

326

Hamilton, Compound Dislocation of the Long Bones.

[Oct.

are apprehensive of this danger (for perhaps if inflammation should come on
it will not yield), it will be better to defer the reduction of the greater joints
at the commencement ; and when the inflammation subsides, which happens
about the seventh or ninth day, then, having foretold the danger from reduc-
tion, and explained how, if not reduced, they will be mutilated for life, we
may try to make the attempt without violence, using also the lever to facilitate
the process."1

In the following quotations from three of the most celebrated writers of
the two last centuries we find but little if any evidence that the opinions of
the fathers upon this subject were not still held in general respect: —

" If the joint be dislocated, so that it is either uncovered, or a little thrust
forth without the skin, the accident is mortal, and of more danger to be re-
duced than if it be not reduced. For if it be not reduced, inflammation will
come upon it, convulsion, and sometimes death. 2. There will be a filthiness
of the part itself. 3. An incurable ulcer, and if perhaps it be brought to cica-
trize at all, it will easily be dissolved by reason of the softness of it ; but if
it be reduced, it brings extreme danger of convulsion, gangrene, and death."2

" Si vero in magnis articulis tarn valida fuit facta luxatio, ut ligamentis
ruptis os articuli multum sit protrusum per integumenta, hsec pars ossis vasis
privata moritur, citius autem si reponatur, quam si non reponitur; quare sola
amputatio restat ad conservationem vitse."3

Heister, who makes no allusion to this subject in the first edition of his
great work, published at Amsterdam in 1739, adds the following remarks in
his last edition, translated and published in London in 1768 : —

" Dislocations attended with a wound, especially of the shoulder or thigh
bone, are of very bad consequence, and often endanger the life of the patient ;
in Celsus's opinion (Book VIII. Chap. XXV.), whether the bones be replaced
or not, there is generally great danger; and so much the more the nearer the
wound is to the joint. Hippocrates has declared that no bones can be reduced
with security, beside those of the bands and feet (Vectiar. 19, 5). See more
on this subject in that passage of Celsus just now quoted, though I by no
means recommend the following him implicitly."4

Such were the extreme views as to the fatality of these accidents, and of -
the feebleness of our resources entertained by the ancient, and even by the
more modern writers almost down to our own day; with only rare exceptions
these limbs were condemned either to great and inevitaWe deformity, or to
amputation. Nor, if we speak only of their fatality, have surgeons ceased to
regard these accidents as among the most grave with which they have to
deal.

Pathology and Appreciation of the Sources of Danger, as compared espe-
cially with Compound Fractures. — The danger, according to Sir Astley
Cooper, consists in the rapid inflammation of the synovial membranes, which

1 Works of Paulus iEgineta, Sydenham ed., vol. ii. p. 509.

2 " Chirurgeon's Storehouse." By Johannes Saultetus, of Ulme, in Suevia. Lon-
don ed., 1674, p. 31.

3 Johannes de Gorter. Chirurgia repurgata. Lugduni Batavorum, 1742. p. 86.

4 General System of Surgery, by Dr. Laurence Heister. 8th ed. London, 1768.
Vol. i. p. 164.

1857.]

Hamilton, Compound Dislocation of the Long Bones.

327

is speedily followed by suppuration and ulceration, whereby the ends of the
bones become exposed; and for the repair of which lesions great general as
well as local efforts are required, and a high degree of constitutional irritation
results. In addition to which circumstances, " the violence inflicted on the
neighbouring parts, the injury of the muscles and tendons, and the laceration
of bloodvessels, necessarily lead to more important and dangerous conse-
quences than those which follow simple dislocations."1

The sources of danger enumerated by Sir Astley Cooper have been re-
garded as sufficient to account for their extraordinary fatality by the majority
of those modern surgical writers who have alluded to the subject ; but I
must confess that to me they do not appear so. In compound fractures the
mortality is far less; yet one might naturally suppose, that when the sharp
and irregular fragments are pressing into the flesh, among nerves and blood-
vessels, the irritation and inflammation would be equal, if not more than equal
to the irritation and consequent inflammation produced by exposing a joint
surface to the air; indeed, modern experience has sufficiently shown that these
surfaces are much more tolerant of atmospheric exposure, and of the action of
many other irritants, than surgeons formerly supposed. A clean incision
into a large joint, which exposes the synovial membranes to the air, and which
permits the products of inflammation to escape freely, is attended with much
less danger than a small puncture which does not at all permit the air to
enter, nor the increased synovia and the pus to escape. Very grave results
sometimes follow from large wounds into large joints, but under judicious
treatment such results are the exception and not the rule.3 But Sir Astley
evidently attributes more of the bad consequences to the exhausting effects of
the efforts at repair, than to the immediate inflammation resulting from the
exposure of the joint. It is pretty certain, however, that a majority of these
patients die at a period too early to render this cause in any considerable de-
gree operative.

As to the bruising of the " muscles and tendons, and laceration of blood-
vessels," it cannot be denied that it must usually be greater than in " simple
dislocations;" and I will not say that it is not in a given number of instances
greater than in the same number of instances of compound fractures. The
tissues have often been thrust rudely through by a large and smooth bone,
and the tendons have been stretched violently or torn completely asunder ;
while occasionally large arteries, which are prone to hug the bones about the
joints, are lacerated and left to bleed. That the importance of these compli-
cations, however, may not be over-estimated, we must state that Sir Astley
Cooper himself has remarked how seldom, in compound dislocations of the

1 On Dislocations and Fractures. Amer. ed., 1851, p. 59.

2 Upon this point see the very able article entitled "Amputations and Compound
Fractures," by John 0. Stone, in the New York Journal of Medicine, vol. iii. of 2d
series, p. 316. Nov. 1849.

328

Hamilton, Compound Dislocation of the Lony Bones.

[Oct.

ankle-joint, the large arteries are injured; that a tearing of the ligaments and
of the tendons is almost as likely to occur in simple dislocations as in com-
pound ; and, indeed, that in neither case are the tendons usually ruptured,
but only thrust aside. Moreover, the skin is often made to give way not so
much from the pressure of the round head within, as from the equal pressure
of some sharp angular body from without. In all of these respects, there are
many examples of compound fractures which possess not a whit of advantage;
in which cases, nevertheless, the surgeon feels very little doubt as to the ulti-
mate cure.

In short, the causes which, according to Sir Astley Cooper, determine the
extraordinary fatality of these accidents, do not sufficiently differ from those
which operate in compound fractures to occasion so great a difference in re-
sults, and the fatality of compound dislocations remains unexplained; or if
surgical writers have here and there intimated the true cause, they have failed
to give it its proper place and value.

I think the cause of the greater fatality of compound dislocations over com-
pound fractures is to be found in the simple fact that dislocations are gene-
rally reduced, and by splints or other apparatus successfully maintained in
place, while compound fractures, as my reports of cases -have proven, are not
generally reduced completely, nor can they by any means yet devised, except
in a few cases, be maintained in place if reduced. Broken limbs, whether
simple or compound in their character, will in a great majority of cases
shorten upon themselves in spite of the most assiduous and skilful attempts
to prevent it.

In adults most bones break obliquely, and cannot be made to support
each other, and even in transverse fractures the broken ends are generally
small compared with the articular ends of the same bones, and afford a very
uncertain and inadequate support for themselves; not to speak of the diffi-
culty of once bringing their ends into exact apposition where the muscles are
powerful, or they lie embedded in a large mass of flesh, so that they cannot
be felt. While, on the other hand, dislocated bones, whether simple or
compound, are capable when restored to place of supporting themselves ; or
with only slight assistance, their reduction may be maintained: it is also
ordinarily a work of no great difficulty to reduce them.

Herein, then, consists the most important difference between these two
classes of accidents, which are in other respects so similar. In the one, the
very nature of the injury prevents the complete reduction, and the consequent
violent strain of the muscles, tendons, and other soft tissues ; while in the
other, the nature of the accident leaves it in the power of the surgeon to
reduce the bones, and modern surgery has in a great measure sanctioned the
practice of maintaining them in place, in defiance of the efforts of the muscles
to shorten the limb, and probably to the imminent hazard of the life of the
patient.

Is it not fair to presume that tissues which have been lacerated and

1857.]

Hamilton, Compound Dislocation of the Long Bones.

329

stretched, require rest in order that they may recover from the effects of their
injuries ? And if the soft parts are really more injured in dislocations than in
fractures, does not the indication for rest become, for this very reason, more
imperative ?

General Inferences. — We have come, then, to regard the shortening of
limbs after fractures, within certain limits and in certain cases, as a conserva-
tive circumstance rather than as a circumstance which the surgeon should in
all cases seek to prevent.

There is abundant evidence that the ancients had some knowledge of the
value of rest to the muscles, tendons, &c, in the prevention of inflammation
after compound dislocations, since they constantly urge the greater danger of
reducing these dislocations, than of leaving them unreduced ; and they do
not hesitate to recommend, that in case violent inflammation supervenes upon
the reduction, the bone shall immediately be again dislocated. Gralen speaks
very explicitly on this subject, and says that " the danger in reduction con-
sists partly in the additional violence inflicted on the muscles, and partly in
their being 6then put into a stretched state, whereby spasms or convulsions
are brought on, and gangrene as the result of the intense inflammation which
ensues;"1 and Paulus iEgineta remarks: "For these, if reduced, occasion
the most imminent danger, and sometimes death ; the surrounding nerves
and muscles being inflamed by the extension," &c.a

I have already quoted from Sir Astley Cooper the causes to which he
attributes in general the great fatality of compound dislocations ; and the
same reasons have generally been assigned by those who have written since
his day ; but he has elsewhere, when speaking of exsection, given place to
the very idea for which we claim so much prominence, the danger arising
from a stretching of the muscles.3 Mr. Liston,4 also, and Mr. Miller,5 when
speaking especially of dislocations of the tibia at the ankle-joint, refer to the
same source of danger.

Treatment. — Let us see now the alternatives which surgery presents for
the treatment of these intractable accidents.

1. Reduction of the bone.

2. Non-reduction.

3. Amputation.

4. Tenotomy.

5. Resection and reduction.

The questions for us to consider are, first, by which of these several methods
is the life of the patient rendered most secure ; and second, where of two or

1 Works of Hippoc, vol. ii. p. 634. Note by the translator.

2 Paulus iEgineta, vol. ii. p. 509.

3 Cooper on Disloc. and Frac, Amer. ed., 1851, p. 270.

4 Liston's Practical Surgery, Amer. ed., p. 97.

5 Miller's Principles of Surgery, Amer. ed., p. 684.

330

Hamilton, Compound Dislocation of the Long Bones.

[Oct.

more methods all are equally safe, by which will he suffer the least maim-
ing or mutilation.

By Reduction. — We have seen already how the old surgeons regarded the
practice of reducing compound dislocations of the larger joints. It is not
difficult, however, to find in the records of surgery numerous examples of
their successful termination under this practice.

In the third vol. of this journal, p. 109, may be found a case of this kind,
in which the dislocation was at the ankle-joint, reported by Dr. White, of
Hudson, N. Y. Pott says he has seen this practice occasionally succeed,1
and Mr. Scott communicated to the Lancet in March, 1837, a case of com-
pound dislocation of the humerus successfully treated by reduction. Sir
Astley Cooper also records several cases of compound dislocations at the lower
end of the tibia and fibula, successfully treated by reduction.

A careful examination, however, of those cases reported by Sir Astley as
having been reduced without resection, and which resulted in cures, does not,
in my opinion, leave much substantial evidence in favour of the practice ; or
perhaps we ought rather to say that it leaves only a qualified evidence of its
propriety in certain cases. He has mentioned about sixteen of these ex-
amples, comprising dislocations of the lower end of the tibia, or of the tibia
and fibula outwards and inwards and forwards, all of which, save one quoted
from Mr. Liston, have been reported to him by other surgeons, and not one
of which he had ever seen himself. Many of the cases are reported very
loosely, evidently in reply to circular letters, and from memory, without re-
corded notes, and by unknown, and in some sense irresponsible surgeons. It
is not always said whether the wounds in the soft parts were made by the
protrusion of the bones, or by some external violence ; yet this is certainly a
very material point in determining whether reduction is to be followed by
inflammation or not. The results, sometimes only accomplished after ex-
posure to great hazards, are, after all, often sufficiently unfavourable.

It will be noticed, also, that in Cases 152 and 153, the astragalus was
comminuted and removed, either at first or at a later day; and in Cases 154,
155, 156 and 160, the tibia, and also probably the fibula, was broken, and
it does not appear but that in consequence of this complication the limb
became shortened, and the muscles were thus put at rest, very much as if the
bones had been retracted ; and in one of the cases enumerated under 161, the
lower end of the tibia spontaneously exfoliated. That a comminution, or
that any fracture of the astragalus or of the tibia and fibula, should be re-
garded in these cases as rendering the accident less grave, can only be com-
prehended by a full appreciation of the value of relaxation of the muscles.

The few cases which remain after this exclusion do indeed illustrate how
nature and skill may triumph over great difficulties, but nothing more.

Non-Reduction. — While, on the other hand, it will be very difficult to find
an equal number of cases of compound dislocations unreduced, which have

1 Chirurg. Works, yoL ii. p. 243.

1857.] Hamilton, Compound Dislocation of the Long Bones. 331

terminated favourably, surgeons who have themselves left such limbs un-
reduced, would scarcely be willing to give them the notoriety of a public
record. In the Transactions of the New York State Medical Society for
1855, I have reported (Case 16 of Tibia and Fibula, p. 87), a compound
disclocation at the ankle-joint, which, being unreduced, terminated fatally on
the twenty- eighth day. This is the only example of a compound dislocation
of a long bone, left unreduced, which has fallen under my observation ; ex-
cepting, of course, those cases in which amputation was practised.

The united testimony, however, of the old surgeons, who generally neither
amputated nor adopted the method of resection, but who recommended and
practised non-reduction, is, that it is much more safe to leave these bones
unreduced, than to reduce them without resection ; and I see no reason to
doubt the correctness of their opinions in this matter. But whether it would
be more safe to leave such limbs unreduced, or having practised resection to
restore them, is another question, in which the advantage and comparative
safety of the latter practice is too obvious to require explanation or defence.

Amputation. — " When this accident (dislocation of the ankle) is accom-
panied, as it sometimes is, with a wound of the integuments of the inner
ankle, and that made by the protrusion of the bone, it not unfrequently ends
in a fatal gangrene, unless prevented by timely amputation, though I have
several times seen it do very well without."1

Says Sir Astley Cooper : " Thirty years ago it was the practice to amputate
limbs for this accident (compound dislocations of the ankle-joint), and the
operation was then thought absolutely necessary for the preservation of life,
by some of our best surgeons." {On Disloc, &c, p. 256.) Nor is it diffi-
cult to see by what reasoning they had fallen back upon this desperate
remedy. Both reduction and non-reduction having proven eminently hazard-
ous, in the absence of perhaps both knowledge and experience in resection,
they finally adopted the alternative of amputation as that which after all
must give to the patient the best chance for life; and were no other
alternatives to be presented, this would be our choice in a large proportion
of cases.

It must not be understood, however, that amputation is an expedient
wholly free from danger ; or indeed that the chances of the patient are in
the average very greatly increased by this practice. Of thirteen amputations
made for compound dislocations at the ankle-joint, in the Royal Infirmary at
Edinburgh, only two resulted in the recovery of the patients.3 Alluding to
which, Mr. Fergusson remarks : "An amount of mortality which may well
incline the surgeon to act upon the doctrine inculcated by Sir Astley Cooper."
(To attempt to save the limb by reduction.) But Mr. Fergusson has added
a sentiment which accords very closely with my own experience and opinions,
ff I fear, however, that in the attempts which have been made to save the

1 Potts' Chirurg. Works, Philada. ed., 1819, vol. i. p. 248.

2 Edinb. Med. Monthly, Aug. 1844.

332

Hamilton, Comjiound Dislocation of the Long Bones.

[Oct.

foot (by reduction) the results in all the cases have not met with the same
publicity ; that the instances where amputation has been afterwards necessary,
or where death has been the consequence, have not always been recorded; and
from what I have myself seen, I would caution the inexperienced practitioner
from being over-sanguine in anticipating a happy result in every example. " —
Fergusson's Surg., p. 281.

By Tenotomy. — As a means of overcoming the resistance of the muscles,
and for the purpose especially of facilitating the reduction, tenotomy has been
proposed. (Seep. 250 of vol. xxxiv. of this Journ.)

This method, based in some degree upon a very correct notion of the prin-
cipal sources of difficulty and of danger in these cases, I regard as totally im-
practicable, at least to any useful or adequate extent. In order to be efficient
all of the tendons passing the articulations must be cut, or nearly all of
them; and I doubt whether the judgment of any discreet surgeon will ever
sanction such an extreme, I might almost say, such an absurd measure. Nor
do I think that in the point of view in which we are now considering this
subject, having reference only to the question of danger, if the cutting of the
tendons was sufficiently extensive to have any real effect in facilitating the
reduction, the practice would be found to have any advantage over other
methods known to be eminently dangerous.

By Resection. — Finally resection presents itself for our consideration as the
only remaining surgical expedient.

We have seen that most of the early writers understood the effects of a
constant strain upon the muscles in increasing the danger of spasms, inflam-
mation and death; but in general they have suggested no remedy but non-
reduction or amputation. Hippocrates, however, uses the following language,
after speaking of resection of protruding bones in accidental amputations, or
in fractures of the fingers : " Complete resections of bones at the joints,
whether the foot, the hand, the leg, the ankle, the forearm, the wrist, for the
most part, are not attended with danger, unless one be cut off at once by
deliquium animi, or if continual fever supervene on the fourth day." ( Op. cit,
vol. ii. p. 638.) To which passage the translator adds the following note :
" This paragraph on resection of the bones in compound dislocations and
fractures contains almost all the information on the subject which is to be
found in the works of ancient medicine/' Celsus notices the practice of resec-
tion in compound dislocations very briefly, as follows : " Si nudum os eminet,
impedimentum semper futurum est; ideo quod excedit, abscindendum est."

Mr. Hey, of Leeds, was the first of the modern surgeons who called especial
attention to the value of resection in compound dislocations.

Subsequently Mr. Parks, of Liverpool, in an " Account of a new method of
treating Diseases of thj Joints of the Knee and Elbow," advocates the practice
of resection in certain cases of diseases of these joints, but especially in
u affections of the joints produced by external violence."1

1 System of Surgery, by Benj. Bell, Edinburgh ed., 1801, vol. vii. p. 360.

1857.] Hamilton, Compound Dislocation of the Long Bones.

333

Mr. Leveille, in France also, following as he affirms the guidance of Hip-
pocrates, has advocated a similar practice.

Yelpeau,1 Symes,3 Fergusson,3 Erichsen,4 Miller,5 Liston,6 Chelius,7 Lizars,8
Gibson,9 Norris,10 under certain circumstances, and especially where the
bones cannot otherwise be reduced, and where the dislocations occur in cer-
tain joints, and especially the elbow and ankle-joints, recommend resection.
To which names we may add that of Sir Astley Cooper, who has considered
the subject, as applied to the ankle-joint, quite at length, and who says : " I
have known no case of death when the extremities of the bone" (tibia, at the
ankle) " have been sawed off, although I shall have occasion to mention some
cases which terminated fatally when this was not done."11

Why resection should diminish the danger to life, by placing at rest the
injured muscles, has been already sufficiently considered; but it seems not
improbable that, if synovial membranes are indeed more susceptible of violent
and dangerous inflammations than the other tissues about the joints, then
would this source of danger be removed just in proportion as the synovial
membranes themselves are removed. Such indeed was the argument used by
Sir Astley; and Mr. South, in a note to Chelius, when referring to this fact,
has made the following statement : —

" In compound dislocations of the ankle-joint with protrusion of the shin-
bone through the wound, most English surgeons saw off the joint end, not
merely to render reduction more easy, but also, according to Sir Astley Cooper's
opinions, to lessen the suppurative process, by diminishing the synovial
surface. This mode of practice is certainly not commonly followed in reference
to other joints, and the younger Cline was always opposed to it being resorted
to in dislocated ankle." (Op. cit, vol. ii. p. 251.)

Case of Compound Dislocation of the Tibia inicards, with Fracture of the
Fibula. Resection of the lower end of the tibia, and recovery with a very useful
limb. — Samuel Adamson, of Buffalo, set. 24, was caught by the cable of a
vessel June 17, 1855, dislocating the left tibia at its lower end inwards, and
breaking the fibula two inches above the ankle. I was immediately called
and found the tibia protruding through the skin about three inches. The
periosteum was torn up, and the cartilaginous surface of the end of the bone
was roughened. His thigh was also severely bruised and lacerated, but the
bone was not broken.

Dr. Boardman assisting me, we attempted to reduce the bones, but with
our hands we found it impossible to do so. I proceeded immediately to re-
move about one inch and a half of the lower end of the tibia with the saw.

I This Journal, vol. xxxiv. p. 250. 3 Principles of Surg., Amer. ed., pp. 332-3.

3 Practical Surgery, 4th American ed., pp. 194, 202, 280, 281.

4 Surgery, Amer. ed., pp. 239, 263. 5 Principles of Surgery, Amer. ed., p. 684.

6 Practical Surgery, 1st Amer. ed., pp. 97-8.

7 System of Surgery, Phila. ed., 1847, vol. ii. p. 251.
s Practical Surgery, Edinburgh ed., pp. 155, 160.

9 Elements of Surgery, 2d ed., vol. i. p. 340. 10 This Journal, vol. xxxi. p. 15.

II Treatise on Disloc. and Frac, Amer. ed., 1851, p. 271.

334

Hamilton, Compound Dislocation of the Long Bones.

[Oct.

The remaining portion was then brought easily into place, and the wound was
dressed with sutures, adhesive straps, bandages, and light splints. On the
same day he became an inmate of the marine wards at the Hospital of the
Sisters of Charity, and was placed under the care of Dr. Wilcox, but through
the politeness of Dr. Wilcox I was permitted to see him frequently.

The wound in the leg healed kindly, and with only a slight amount of in-
flammation and suppuration. Violent inflammation, however, occurred in the
thigh, followed by extensive suppuration and sloughing. This, in fact, proved
to be by far the most serious injury, and that which most endangered his life
and delayed his recovery.

After about two months, the ankle was in such a condition as to require
little or no further attention. The fragments of the fibula had shortened upon
each other, and were united so that the tibia rested upon the astragalus. It
was nearly two months, however, before he began to walk, owing to the con-
dition of his thigh.

Aug. 24, 1856, fourteen months after the accident, Adamson called at my
office. He is now employed again as a sailor on board the schooner Sebas-
topol, and performs all the duties of an ordinary deck hand. His leg is
shortened one inch and a quarter; from which, it seems, that there has been
some deposit upon the end of the bone, which has compensated for one-quarter
of an inch of that which I removed. The ankle is perfect in its form, being
neither turned to the right nor to the left, and he treads square and firm upon
the sole of his foot. There is considerable freedom of motion, especially in
flexion and extension. Occasionally it becomes a little swollen and painful.

The following case also, although not a dislocation, will serve to illustrate
the same principle : —

Compound Comminuted Fracture of the Radius. Resection of a portion of
the Ulna. Recovery. — William Croak, of Buffalo, set. 30. Jan. 29, 1856, a
large piece of iron casting fell upon his arm, crushing and lacerating the wrist,
and comminuting the lower part of the radius; he was immediately taken to
the Hospital of the Sisters of Charity. I found the whole of the soft parts
torn away in front of the joint, and the fragments of the radius projected into
the flesh in every direction. The hope of saving the hand seemed to be
scarcely sufficient to warrant the attempt ; at least by the ordinary mode of
procedure. I, however, stated to the gentlemen present, among whom were Dr.
Rochester, my colleague, and the house surgeon, Dr. Lemon, that I believed
it could be saved if, having removed the fragments of the radius, we practised
resection of the lower end of the ulna, and allowed the muscles to become
completely relaxed. Accordingly, after placing my patient under the influ-
ence of chloroform, I enlarged the wounds so as to enable me to remove six
or seven fragments of the radius, leaving others which were broken off but
not much displaced. I then removed with the saw one inch and a half of the
lower end of the ulna. The hand was immediately drawn up by the contrac-
tion of the remaining muscles, but their tension was completely relieved.

The wounds were closed and dressed lightly, and the whole limb was placed
on a broad and well padded splint covered with oil cloth. The hand, which
was very pale and exsanguine, was covered with warm cotton batting.

The subsequent treatment was changed from time to time to suit the indi-
cations; but his recovery was rapid and complete, nor was there at any time
excessive inflammation in any part of the limb.

I have not seen him within the last two or three months, and I am at pre-

1857.] Hamilton, Compound Dislocation of the Long Bones. 335

sent unable to say how useful his hand has become. I am satisfied, however,
in a knowledge of the fact that it is saved.

In a case of compound dislocation of the upper end of the humerus, occur-
ring also under my own observation, and recorded in the Transactions of the
New York State Medical Society for 1855 (p. 27, Case 14), in which reduc-
tion was followed by death, I have now much reason to believe that if I had
practised resection before the reduction, my patient's chances for recovery
would have been greatly increased ; perhaps, also, the case of compound dis-
location at the wrist-joint recorded in the same vol. (p. 68), in which, having
reduced the bones, I was subsequently compelled to amputate, may equally
illustrate the hazard to which the practice of reduction without resection must
often expose the patient.

The same remarks I will venture to apply to the case of compound dislo-
cation of the hip, of which I have already spoken as having occurred in the
practice of Dr. Walker, of Charlestown, Mass. Had the head of the femur
been resected before its reduction, I cannot doubt but that the unfortunate
man's chances for recovery would have been very greatly improved.

Thus, if we consider the question of the life of the patient only, the argu-
ment and the testimony seem to favour resection in a great majority of cases
of compound dislocations occurring in large joints, and in a considerable
number of cases of similar accidents in the smaller joints. It is certainly
more safe than non-reduction or reduction without resection, and it is proba-
bly quite as safe as amputation or tenotomy.

But there is another question, which is, in our estimation, secondary to the
one now considered, but which is often, in the estimation of the patient him-
self, of the first importance — namely, by which method will he suffer the least
maiming or mutilation ?

This question I do not find it difficult to answer. Certainly it is not by
non-reduction or by amputation; and, putting tenotomy aside, it is now a ques-
tion only between reduction without resection, and reduction with resection.
These two methods, one of which experience has shown to be fraught with
danger, and the other of which experience has shown to be relatively safe, are
now to be compared in a point of view in which their antagonisms are per-
haps less conspicuous, yet sufficiently marked.

First. In either case the inflammation consequent upon the injury may be
violent, and the recovery slow and tedious. The same arguments, however,
which we have applied to the question of the comparative danger of the two
modes, must apply with nearly equal force to this question of maiming; since
the amount of maiming must often be governed by the intensity and duration
of the inflammation, and upon this point the testimony has been shown to be
in favour of resection.

It will be observed that not only is the danger of maiming rendered more
considerable by reduction without resection, because the inflammation is so

336 Hamilton; Compound Dislocation of the Long Bones.

much more likely to extend to the tendons and muscles, causing them to ad-
here to each other, and to become subsequently atrophied, a condition from
which they often never completely recover, but also because the ligaments
and capsules of the joints, with the synovial surfaces, are in consequence en-
croached upon, and the freedom of motion is ever afterwards greatly restrict-
ed, if not completely lost. This marked impairment of the functions of the
joint does not always happen, but it cannot be denied that it does generally.
Indeed it is by no means uncommon for these accidents to be followed, after
ulcerations of the cartilage, by copious bony deposits in and around the
joints.

How is it, on the other hand, with these joints after resection? I have
thus far heard of no cases in which complete anchylosis resulted ; but in all
considerable freedom of motion has returned, and in some the restoration in
this respect has been nearly or quite as complete as before the accident.

Says Dr. Kerr, of Northampton : —

" Several cases of compound dislocation of the ankle have fallen under my
care, and it has been uniformly my practice to take off the lower extremity of
the tibia, and to lay the limb in' a state of semiflexion upon splints ; by this
means a great deal of painful extension, and the consequent high degree. of
inflammation, are avoided. The splints I used are excavated wood, and much
wider than those in common use, with thick movable pads stuffed with wool.
I keep the parts constantly wetted with a solution of liquor ammonias acetatis,
without removing the bandage. In my very early life, upwards of sixty years
ago, I saw many attempts to reduce compound dislocations without removing
any part of the tibia; but, to the best of my recollection, they all ended unfa-
vourably, or, at least, in amputation. By the method which I have pursued,
as above mentioned, I have generally succeeded in saving the foot, and in pre-
serving a tolerable articulation."1

Sir Astley Cooper has made a valuable experiment to determine the con-
dition of the new joint under these circumstances; and the vast number of
cases in which resection has now been practised in cases of caries of the arti-
culating surfaces, and their results, add still more substantial proofs as to the
usefulness of the joints after such operations.

"I made an incision upon the lower extremity of the tibia, at the inner
ankle of a dog, and cutting the inner portion of the ligament of the ankle-
joint, I produced a compound dislocation of the bone inwards. I then sawed
off the whole cartilaginous extremity of the tibia, returned the bone upon the
astragalus, closed the integuments by suture, and bandaged the limb to pre-
serve the bone in this situation. Considerable inflammation and suppuration
followed; and in a week the bandage was removed. When the wound had
been for several weeks perfectly healed, I dissected the limb. The ligament
of the joint was still defective at the part at which it had been cut. From the
sawn surface of the tibia there grew a ligamento-cartilaginous substance,
which proceeded to the surface of the cartilage of the astragalus, to which it
adhered. The cartilage of the astragalus appeared to be absorbed only in one
small part; there was no cavity between the end of the tibia and the cartilagi-
nous surface of the astragalus. A free motion existed between the tibia and
astragalus which was permitted by the length and flexibility of the ligamentous
substance above described, so as to give the advantage of a joint where no

1 Cooper on Dis. find Frac, p. 275.

1857.]

Lee, Natural Range of the Heart's Sounds.

337

synovial articulation or cavity was to be found. This experiment not only
snows the manner in which the parts are restored, but also the advantage of
passive motion ; for if the part be frequently moved, the intervening substance
becomes entirely ligamentous ; but if it be left perfectly at rest for a length of
time, ossific action proceeds from the extremity of the tibia into the ligamentous
substance, and thus produces an ossific anchylosis."

Second. Is it not probable, moreover, since the limb can be retained in
place so much more easily after resection, that it will actually, in a majority
of cases, be found to have been retained in place more perfectly 1 Even after
simple dislocations, especially in those occurring at the ankle-joint, great de-
formity and much maiming are the not unfrequent results, and that too when
all diligence and care have been employed. It has been impossible always
to maintain a perfect apposition in the articulating surfaces. How much
greater must be this difficulty in cases of compound dislocations !

Third. The only argument which remains in favour of reduction without
resection is the necessary shortening of the limb after resection. But this
need seldom perhaps to exceed three-quarters of an inch, and often not more
than half an inch; an amount of shortening which, as I have had occasion
to prove when treating of fractures, does not necessarily produce a halt, and
which indeed is often not known to exist by the patient himself.

Finally, it must not be inferred that the writer intends to recommend re-
section as a universal practice in cases of compound dislocations of the long
bones. He has only sought to determine in a general manner its relative
value as compared with other modes of procedure; and especially has it been
his intention to bring more prominently into view the importance of rest and
relaxation to the muscles, as an element in the treatment most essential to
success. To declare its special application to cases would demand a treatise
more elaborate than it was proposed to write. If, however, one were to speak
of the individual bones only, there seems sufficient authority in the facts and
arguments already presented to conclude that resection is applicable to certain
compound dislocations of the clavicle, humerus, radius and ulna, fingers,
femur, tibia and fibula, and toes; in short, to all of these accidents occurring
in the long bones of the extremities.

Art. III. — Clinical Remarks on the Natural Range of the Heart's Sounds..
By Chas. A. Lee, Ml D.

Physicians who have not paid much attention to physical diagnosis, as-
connected with diseases of the heart, are often led astray by the signs derived
from the extent of the sounds of the heart, without any regard to their

1 Cooper on Disl. and Fract. p. 281.

No. LXVIIL— Oct. 1857. 23

338

Lee, Natural Range of the Heart's Sounds.

[Oct.

quality. This mistake is rarely, if ever, made by those who have studied
this class of diseases as a specialty, and who have had opportunity of verifying
their diagnosis by autopsic examinations. I have frequently been called in
consultation, where the patient has been supposed to labour under incurable
hypertrophy, valvular, or some other disease of the heart, merely because
the cardiac pulsations extended over a greater space than natural, and were
distinctly heard in situations where, under ordinary circumstances, they are
not heard at all. We do not refer to cases where the conducting power of
the pulmonary tissue has been increased by tubercular deposit, pulmonary
apoplexy, chronic consolidation of the lung or hepatization, the effusion of
pleurisy, cancerous deposit, &c. ; but where there is no evidence of pulmonary
disease, or any mechanical cause which would be likely to increase or extend
the cardiac sounds; and this error in diagnosis has been, no doubt, often
occasioned by the erroneous teaching of some of our standard authorities on
these affections.

Thus Laennec, the earliest writer on this subject, remarks that, " in a
healthy person, moderately stout, and whose heart is well proportioned, the
pulsations of this organ are only heard in the cardiac region, that is, the space
comprised between the cartilages of the fourth and seventh ribs, and under
the lower end of the sternum." (O/i Diseases of the Chest, Am. ed., p. 571.)
This writer also states that in fat persons, the space in which the pulsations
can be detected by the stethoscope, is sometimes not more than an inch square;
but that, in thin persons, in the narrow-chested, and in children, the pulsations
are more extended — being perceptible over the third, or even three-fourths of
the lower part of the sternum, and sometimes over even the whole of this
bone ; also, on the left side, as high as the clavicle, and sometimes, though
feebly, under the right clavicle.

Now, the fact is, as Andral has remarked, that it is not so uncommon for
the pulsations of the heart to extend along the sternum and costal cartilages
of the right side as far as under the ciavicle, and that, too, in subjects not
children, or thin, or narrow-chested ; and so common is this the case in all
possible conditions of health for pulsations to be heard in the right side of
the chest, that it should not be considered as indicating any pathological
condition. Yet Laennec tells us that " when the pulsation of the heart is
heard over a greater extent than what is above stated to be the range of a
well-proportioned organ, the individual rarely enjoys good health, and on
examination will be found to labour under some of those symptoms of cachexia
peculiar to some diseases of the heart; if he has not formal dyspnoea, his
respiration is, at least, shorter than usual, and he is probably subject to palpi-
tation." I need hardly observe that these statements are not supported by
more recent observations. This writer, moreover, observes that when the
pulsations of the heart become more extended than the points first mentioned,
they are heard successively in the following places : 1. The whole left side
of the chest, from the axilla to the stomach ; 2. The right over the same

1857.]

Lee, Natural Range of the Heart's Sounds.

339

extent; 3. The posterior part of the left side of the chest; and 4. The
posterior part of the right side; and the intensity of the sound, he remarks,
is progressively less in the succession mentioned — that is, it is less under the
right clavicle than under the left; less on the lateral parts of the left side
than under the clavicle ; still less perceptible on the right side laterally, and
scarcely ever heard on the right side posteriorly. But there are so many
exceptions to the above rule, as to render it of little practical value in diag-
nosis. For instance, in very thin persons the pulsations may generally be
heard over the whole chest, both anteriorly and posteriorly; and in pregnancy
it is very common to hear the first sound below the umbilicus. Bouillaud, in
his work on Diseases of the Heart, tells us that he has, in the subjects belong-
ing to the category specified by Laennec, not only heard the sounds of the
heart once, but many hundred times in the regions indicated above; also, in
all other parts of the chest, without excepting the right posterior region ;
also, at the lateral parts of the neck, a situation where, he states, they are
very often almost as loud as in the praecordial region itself. The scale of
Laennec, however, will not be likely to mislead, if we make ourselves fully
acquainted with the causes and circumstances which produce an irregular
propagation of sound, which will be noticed directly. This subject, of the
extension of the sounds of the heart, derives its importance chiefly from the
fact that Laennec, as well as other writers, regard such extension as a frequent
sign of cardiac disease. Indeed, this writer observes that, " with regard to
the relation between the state of the heart and the extent of its pulsations,
it may be taken as a general fact, that the extent of pulsation is in the direct
ratio of the thinness and weakness of the heart, and consequently, inversely as
its thickness and strength."

Laennec held that the size of the heart favoured the extent of pulsation,
unless the walls were hypertrophied, when it was diminished. If the pulsa-
tions were heard over all the regions above designated, then we can safely
infer, he says, that one or both ventricles are dilated, and this presumption
will be strengthened if the pulsations are as great under the clavicle, or in
the axilla, as in the region of the heart ; but if the pulsations cannot be heard
posteriorly, nor in the right side, while they may be heard in the other places,
and if their intensity is nearly equal in all these, we may conclude that the
ventricles are moderately dilated, and the walls of the heart naturally thin.
This pathologist taught, also, that if the pulsations are felt very strong in the
region of the heart, and are not perceived at all or only very slightly under
the clavicle, we may conclude that there is hypertrophy of the ventricles. As
a general rule, then, if the Father of Auscultation is to be believed, a great
extent of sound is a mark of thin parietes of the heart, especially the ventri-
cles ; while a confined range of sound coincides with an increased thickness
of these, and he considered this mode of graduating the extent of the' cardiac
sounds one of great certainty and practical value; indeed, he seems to have
regarded his scale as one by which we might attain to nearly mathematical

340

Lee; Natural Range of the Heart's Sounds.

[Oct.

exactness in judging as to the state of the cardiac walls. I need hardly say
that the teachings of this distinguished pathologist, on these points, are re-
garded as of little positive value at the present time, especially when taken
by themselves alone ; in connection with other signs, they have a certain kind
of value, as interpreting or corroborating them.

According to Hope, other things being equal, the sounds of the heart are
louder, and of course audible over a greater extent of surface in hypertrophy
with dilatation; while in simple hypertrophy, the impulse is increased, while
the sounds are diminished. All writers on this subject admit that, in a mere
thickening of the walls of the ventricles, without dilatation, the first sound
is louder, shorter, and clearer than natural, somewhat like the second sound
produced by a sudden extension of the semilunar valves. If the walls are
dilated as well as thinned, then the first and second sounds become so similar
that they can hardly be distinguished, except by position and their corre-
spondence, or the contrary with the arterial pulse. As the flow of blood in
the arterial tubes is retarded considerably in dilatation, the finger should be
placed on the carotid, instead of the radial artery. We shall find the second
as well as the first sound of the heart, increased in dilatation, unless there be
softening present, when the sounds will be greatly modified.

In judging of the degree of dilatation, Dr. Hope recommends us to observe
how far the first sound resembles the second, and to compare the intensity of
the first, heard immediately over the ventricle affected, with what we conceive,
from experience, would be its intensity in the same subject if the heart were
healthy. This rule is, doubtless, superior to that of Laennec ; and yet, it is
not very easy of application in all cases. There are so many causes which
modify the action of the heart, some of them altogether independent of its
structure, and which, to a certain extent, moreover, are inappreciable, that
any conclusions deduced from the application of this rule alone must be, to a
great degree, unreliable. We should judge of attenuation by the first sound,
as Hope states, less by its loudness than by its greater shortness and clear-
ness ; its more complete assimilation to the second sound. But I apprehend
it would be very unsafe for us to diagnosticate dilatation with thinning of the
ventricular walls, merely because we have a loud, quick, sharp, first sound,
approximating to the second ; for we often meet with the same sound, if I am
not mistaken, in anemic subjects of a highly nervous temperament. Under
these circumstances I have, in a fit of palpitation, often known the cardiac
sounds audible to a considerable distance from the patient, while the whole
chest was shaken by the violent throbbing of the heart. In a large majority
of these cases of palpitation, there is undoubtedly, dilatation of the heart,
with attenuation of its walls ; but in a large number, the heart is found, on
examination, to be in all respects normal. The opinion of Hope differs from
that of Laennec in regard to the effect of dilatation with hypertrophy on the
sounds of the heart; for while he believes that the effect is to render the
sounds louder, the latter infers the contrary, and says we " may consider it as

1857.]

Lee, Natural Range of the Heart's Sounds.

341

constant, that the extent over which the beats of the heart are audible, is in
the direct ratio of the feebleness and thinness of its walls." Within certain
limits, we should say that the opinion of Hope seems by far the most plausible;
inasmuch as in very great dilatation, the walls will be unable to contract
smartly, and the sounds must necessarily be weak, as is always the case near
to dissolution and in ramollissement. But if hypertrophy exceed certain
limits, then the sounds must be rendered comparatively dull from slow con-
traction. It is impossible, from the very nature of the subject, to lay down
any rule of universal application.

There is no fact better known in cardiac pathology than that hypertrophy
has the effect of deadening the sounds of the heart, especially the first sound, or
that produced by ventricular contraction; and its dulness and prolongation
will be proportioned to the degree of hypertrophy present; and I have known
cases where it was nearly extinct. If heard at all it will be between the fifth
and sixth ribs, or where the apex of the heart strikes against the walls
of the chest, while the second sound will be heard best over the sigmoid valves
and up along the course of the aorta and pulmonary artery. If there is con-
traction with hypertrophy, the sounds will be proportionably weaker. We need
not remark that it is only in hypertrophy of both ventricles that we may expect
the sounds confined within very narrow limits. In hypertrophy, then, with
dilatation within certain limits, we have the loudest sounds, especially during
palpitation, so loud that they may be heard over the whole chest anteriorly
and posteriorly, especially in thin subjects and children. In proportion to
the dilatation the first sound will be similar to the second, short and smart,
from the sudden extension of the auricular valves ; the second sound is louder
than natural from the quickness of the ventricular diastole.

Mr. Hughes coincides in the views of Hope, viz : that there will be in-
creased resonance of the sounds of the heart, when, the valves being healthy,
the chambers of the heart are dilated and the parietes of the ventricles thinner
than natural. He explains the phenomenon, also, in the usual way, that is,
while the flapping action of the valves is free the contraction and dilatation
of the ventricles are more rapid and smart ; the agitation of the fluid which
they contain is, consequently, greater than in a healthy state of the organ,
and, of course, the vibrations communicated to the surrounding solids are in-
creased. The back-stroke, so called, which is heard in these cases, is a loud,
clear, and flapping sound, and is doubtless owing to the rapid dilatation of a
large ventricle.

Dr. Gerhard states {The Diagnosis, Sc., of Disease of the Chest, Phila.,
1846) that simple loudness of the first sound of the heart depends either
upon a temporary condition of the heart, that is, a simple febrile movement
or nervous action, or upon a hardening of the muscular structure of the heart,
perhaps, conjoined with slight obstruction of the semilunar valves, in which
latter case " the increased loudness may continue for a very long period."
But when the sounds are increased from this cause, there will be roughness,

342

Lee, Natural Range of the Heart's Sounds.

[Oct.

or a bellows or rasping sound, some modification of the normal sound, and as
to the increase of sound from a hardening of the muscular structure, as this
would tend to impede the cardiac contractions, it may well be doubted whether
the effect would be such as is suggested.

We have said enough to show that there is no natural and healthy limit to
the heart's sounds even in health, and there is no practical utility in aiming
at great precision in regard to this point. It is certain that the praecordial
region does not define this boundary, for the second sound always exceeds
that limit, being propagated along the aorta and pulmonary artery, and in
regard to the first sound, there is an infinite variety in this respect ; in no
two individuals, indeed, can it be said that the sounds are limited to precisely
the same boundaries. There are so many causes extraneous to the heart itself,
which modify its sounds, that no precision can ever be arrived at in the rules
laid down on this subject. In persons of a highly nervous temperament the
sounds will be heard generally beyond the praecordial region even when not
labouring under excitement; but if -excited, or palpitation be present, there is
scarcely any limit within which they are confined. They will, also, be of a
higher pitch, and the extent to which they may be heard will be proportioned
to the pitch. It is so in all cases of nervous palpitation, so called. Is there
anything in the character of the sounds in such cases which throws any light
on the question ? Whether there be any dilatation of the heart or attenuation
of its walls, we can only say that, as a general rule, clear and shrill sounds,
if not particularly loud, indicate attenuation of the parietes, while both loud
and clear sounds point to enlargement of the cavities as well as thinness of
the walls j but a healthy or normal heart in a person of nervous temperament
will, as before remarked, give forth loud sounds, which will be widely propa-
gated over the chest. We saw this fact well illustrated in a recent case. We
were summoned in haste to visit a lady who was said to be dying from disease
of the heart. We found her homoeopathic physician present, and the neigh-
bouring women assembled "to be in at the death." The household were in
dire commotion, the husband and children in tears and inconsolable. By ex-
amination no signs of organic disease of the heart could be detected except,
perhaps, slight enlargement from dilatation, but there was no valvular disease.
There was severe palpitation, which gave forth a sharp, clear sound, and this was
propagated over the entire chest, anteriorly and posteriorly. It was hearing
the sounds over the right side that led her physician to pronounce the case
one of enormous enlargement of the heart, which must soon prove fatal. The
fears of the patient having been allayed, and an opiate administered, the pal-
pitations soon ceased, and the patient was, in a few days, in the enjoyment of
her usual health. Such cases are often met with.

The extension of the sounds of the heart, then, does not necessarily indicate
disease of the organ in a majority of cases; perhaps it points to some morbid
condition of the lungs by which their power of propagating sound is increased.
We have already alluded to some of these conditions, as tubercular deposit,

1857.]

Lee, Natural Range of the Heart's Sounds.

343

hepatization, pulmonary apoplexy, pleuritic effusion, cancerous infiltrations,
pulmonary oedema, and, perhaps, dilatation of the bronchi, the existence of
which can ordinarily be ascertained with great certainty by the history of the
case and the usual diagnostic signs ; while we are to remember that the sounds
will be diminished, also, by a great variety of causes, as hypertrophy or thick-
ening of the cardiac walls, causing slow but strong contractions, atrophy, soft-
ening, by anything which interferes with the free motion of the valves or the
free action of the heart itself, local atony, general debility, anything which
prevents full and free contraction, thus diminishing the sudden extension of
the valves, as in hydro-pericarditis or emphysema of the anterior border of the
left lung, want of pliancy in the valves, owing to ossification or atheromatous
deposit, &c. Sometimes, also, the natural sounds of the heart are obscured
by pericardial murmurs, or by bronchial rales ; or, abnormal murmurs, arising
from one valve, may hide or obscure the natural sounds arising from another.

I have intimated that our books attach too much importance to this increase
of the natural range of the heart's sounds, as a sign of cardiac disease; whereas,
it does not, necessarily, indicate any disease whatever of the organ, the cause,
perhaps, being wholly extraneous. There is, also, much erroneous teaching
in our standard works regarding this point. Thus, for example, the American
editor of Williams' work On Diseases of the Respiratory Organs, remarks:
"When the lungs are healthy, the intensity of the heart's sounds is directly
as the distance of the point at which they are examined from their centre of
production." No allowance is made for anything except the increased con-
ducting power of the lungs from disease. The young practitioner needs being
cautioned on this point, or he will be very likely to draw erroneous conclusions
from this class of phenomena. In disease it is not the natural, but the abnor-
mal sounds or murmurs he is to study, their character, their seat, their extent,
and especially their causes. As a point de depart, he must accurately fix in
his mind the natural situation and limits of the heart; its normal sounds,
their causes and mechanism, their rhythm and usual boundaries, and the cir-
cumstances which lead to their extension; the relative situation of the different
valves, their offices and functions, &c. ; in short, everything relating to the
anatomy and physiology of the organ. When this is all acquired he may then
proceed to study its pathology, to learn how a modification of its sounds and
motions grows out of change or modification of structure, as hypertrophy,
dilatation, thinning of its walls, ossific or other valvular deposits, contraction
of its cavities, softening, inflammation of its lining membrane or its peritoneal
sac, polypus, malformations, aneurism of the aorta, &c. He will thus learn
to distinguish structural from functional diseases of the organ, as neuralgia of
the heart, or angina pectoris, palpitation, syncope, &c, and he will not be apt
to confound simple extension of the normal sounds of the heart with organic
disease of the organ ; and this class of diseases, moreover, can only be studied
to advantage in hospitals where numerous cases are presented, and where the
symptoms during life may be connected with autopsic appearances. The ear

344 Bond, New Splint for Diseases and Injuries of Elbow-Joint. [Oct.

is to be cultivated by assiduous and systematic practice so as to detect the
slightest deviation from the normal sounds, and this deviation must be at once
traced up to its anatomical and physiological cause. There is something, more-
over, peculiarly attractive and even fascinating to an investigating mind in the
study of this class of diseases; there is not only the pleasure and the excitement
consequent on the investigation of morbid phenomena, but there is the satis-
faction growing out of a discovery of their causes, as confirmed by the unerring
scalpel. In regard to many other diseases, where physical diagnosis is inap-
plicable and post-mortem research fails to reveal their secret and hidden seats,
there is a painful uncertainty and mystery thrown around them, and so un-
satisfactory have been all former attempts to reveal their pathological nature,
that the mind instinctively shrinks, almost, from grappling with them. Such
are tetanus, hydrophobia, neuralgia, &c. But, in diseases of the heart, the
practised hand and the cultivated ear rarely meet with any insuperable obsta-
cles. Here symptoms become signs which infallibly point to their pathological
cause. Principles, and laws, and rules are thus deduced, which serve as a
point of departure for all future study and observation.

At present I have only taken up one phenomenon, one of the least important
of all the phenomena connected with the heart, to show how, from imperfect
observation, or rather from ignorance, its importance has been overrated, and
how inferences have been drawn from it, not warranted by any of the facts of
cardiac pathology, and that the existence of organic disease of this organ is to
be ascertained by a different class of phenomena, viz., unnatural sounds or
murmurs, and by percussion.

Art. TV. — Description of a New Splint for Dressing Diseases and Injuries of
the Elbow-Joint. By Henry Bond, M. D. (With a wood-cut.)

Several years ago, I had under my care a severe case of scrofulous dis-
ease of the elbow, where it was important to relieve the joint from the irrita-
tion occasioned by flexion, extension or pressure, and for a long time to keep
remedies continuously applied to the part. The patient was a very responsi-
ble officer in a public institution of the first importance, and his services at
that time were nearly indispensable, and required much time and very
close and careful attention. It was, therefore, desirable to adopt a dress-
ing that would interfere the least with the discharge of his official duties,
and, at the same time, admit the most efficient treatment of the disease. I
examined surgical books, and visited the shops of surgical instrument-makers;
but I found nothing that seemed to meet satisfactorily the desiderata in his
case. One objection was that none of them would afford a comfortable, as
well as secure, rest or support to the affected limb; and this was a point of

1857.] Bond, New Splijit for Diseases and Injuries of Elbow- Joint. 345

some importance, at least to the patient, in a case where the dressing was to
be worn continuously for months. As the joint, at first, was found at an
inconvenient obtuse angle, and, if the limb were saved, it would probably be
with anchylosis, one object was to bring it to a right angle, by the use of a
jointed splint. But the chief objection was that, in cases of enlargement of
the joint from whatever cause, whether from scrofula, as in the case then
before me, or from the inflammation and tumefaction, very often attendant on
severe injuries of the elbow, they must press upon the part affected, unless a
large amount of cushions and compresses be employed; and whenever a splint
requires this, it is an evidence of its imperfect adaptation to the case, and the
difficulty of its application is correspondently increased. The unskilful use
of compresses is the cause of a large proportion of the deformities resulting
from fractures.

In this emergency I contrived a splint, which was made for me by my
friend, the late Mr. John Borer,1 and which proved to be entirely satisfactory
to myself and to my patient. As I see no one, among the several splints,
illustrated in the recent report of Dr. F. H. Hamilton, nor in other late
works on surgery, which seems to me so well adapted to the treatment of
such affections, I will offer the contrivance to the trial of others, if you,
Mr. Editor, shall think sufficiently favourably of it, and that I have not mis-
judged its utility. I do this the more confidently, from the statement of Dr.
Mutter, that he had made use of it with entire satisfaction, and had exhibited
it repeatedly to his class, pronouncing it superior to any other apparatus for
the treatment of such affections.

Explanation of the Figure. — A, A, two steel plates, each about one inch
wide and seven inches long, united in a joint, the motion of which is con-
trolled by three screws. The central screw is the pivot upon which the joint

1 This splint may be obtained of Mr. J. H. Gemrig, at 109 South Eighth Street,
below Chestnut.

346 Bond, New Splint for Diseases and Injuries of Elbow-Joint. [Oct.

moves. The other screws are inserted through two fenestras in the outer
plate; and these fenestras are of such a length or extent, as to allow the re-
quisite variation of the angle, from a right angle to a very obtuse one, and
so narrow that the heads of the screws when driven in will press upon their
edges. Where the screws are partially withdrawn, the joint may be moved,
and such an angle assumed as the limb to which it is to be applied may
require ; and then the screws are to be driven in firmly. Where the steel
plates come in contact with each other, they should be made rough, or their
polish taken off by filing or grinding; otherwise the screws may not always
prevent the sliding of one plate upon the other. At B, B, about an inch
and a half from the pivot-screw, there is a double bend in each plate, in order
to throw out the joint so far (about J of an inch), that it may not press upon
or touch the swollen elbow.

C and D, two tin plates (tinned iron), each about four or five inches wide;
the upper one ( C), which is intended for the arm, about seven inches, and.
the other (D), intended for the forearm from nine to eleven inches in length,
the dimensions of each varying according to those of the limb, to which the
splint is to be applied. They may be made of such light tin-plate, as to be
easily bent and adjusted to the limbs. The edge of the lower end of D is
bent or turned outward, so that it may not present a sharp edge to the wrist
or hand that may rest upon it. Upon the convex or outward side of each
are tin loops for the insertion of the steel plates; and these are to be shoved
in so as to bring the tin plates more or less near to the elbow, accordingly as
its condition may admit or require. The tin loops are not attached midway
between the lateral edges of the tin plates (as they appear to be in the wood-
cut, which presents only a direct lateral view, or profile of the splint), but
are so attached that the tin plates will extend quite round behind the arm,
and under the forearm.

Where no artisan is at hand competent to make such a joint as is de-
scribed above, the surgeon may direct any black or tin smith to rivet two
steel plates together, at the required angle, and to make the double bend in
each plate, as seen at B, B. A series of steel plates thus riveted together
at various angles, would be a useful substitute for a movable joint in cases
where it may be necessary to vary the angle of the elbow.

The patient was of a decidedly scrofulous diathesis, which had been re-
peatedly evinced by affections of the glands, the skin, and the eyes; and
the treatment was, therefore, both constitutional and local. Tonics, both ve-
getable and mineral were employed; but the chief reliance was placed on the
use of iron, in different forms, either the iodide or the tartrite in the form of
a saline chalybeate, imitating the Cheltenham water. The following formula
was employed much more than any other: R. — Magnes. sulph. ^j ; Potass,
bitart. 5j; Ferri sulph. gr. x. Dissolve this in a quart of water and take
from .^iij to ^vj, daily, in divided doses, varying the quantity according to
the condition of the bowels; using enough to keep them free, but not

1857.] Lente, Ready Method in case of Infant born Asphyxiated. 347

enough to produce purgation. Bathing and attention to diet were not
neglected. Sea-air and sea-bathing were resorted to for a short time.

Leeches and blisters were employed at first, and some use was made of
tinct. of iodine; but the local remedy chiefly relied on was a solution of
iodid. potass. (3iv to 5vj in water ^xvj), sometimes alternated by the employ-
ment of a solution of muriate of soda. Strips of soft, thick muslin or can-
ton-flannel, thoroughly wetted with the solution, were wrapped around so
as to cover the affected part, and this was immediately covered with oiled
silk. The silk protected the sleeve from the solution and prevented evapora-
tion, so that by renewing the dressing every eight or twelve hours, the elbow
remained constantly moistened by the solution ; and this was continued many
weeks. The splint, with a thin lining of flannel or wadding, was secured to
the arm by a roller, or more frequently in warm weather by a few strips of
muslin tied around.

This dressing, with the splint well adjusted to the size of the limb, added
so little to the dimension of the limb, that the patient could wear a loose
sleeve. A sling was sometimes used, but it was oftener omitted, the lightness
of the dressing rendering it less necessary than is usual in the treatment of
such affections.

The patient entirely recovered from the scrofulous affection, with some en-
largement of the bones, and a partial use of the elbow-joint.
July, 1857.

Art. Y. — Successful Employment of Marshall Ball's Beady Method in the
Case of an Infant born Asphyxiated. By Frederic D. Lente, M. D., of
Cold Spring, N. Y. (With a wood-cut.)

Since the enunciation of Dr. Hall's rules for the recovery of drowned
persons and stillborn infants, a suflicient number of instances of their prac-
tical application- to such cases have been afforded the public by his medical
friends in Great Britain to prove their great superiority over every method
previously employed. I have not as yet met with any public testimony of
their efficacy on this side the water, with one exception. A remarkable
case of the recovery of a patient, poisoned by laudanum, by this method, was
reported to the Society of Statistical Medicine, Jan. 12, 1857, by Dr. Lewis,
of New York. [See N. Y. Journ. of Med. for Mar. 1857, and Am. Joum.
of Med. Sci. for April.] Regarding this as one of the most important steps
in the advancement of medical science, it affords me great pleasure to be able
to present a very satisfactory instance of its successful application.

Mrs. H., aged about 25, was taken in her second labour June 29th, 1857.
In the previous labour, the presentation was breech; and, owing to the delay

348 Lente, Ready Method in case of Infant born Asphyxiated. [Oct.

in the latter part of the labour from subsidence of the pains, the child was
stillborn and could not be resuscitated. In this, her second confinement, the
presentation was natural, and the labour progressed regularly and satisfactorily,
the pains being very severe towards the last, until the head passed the outlet,
when, as before, the pains ceased entirely. Finding, after a few minutes'
delay, that the child was struggling for breath, and that pulsation in the cord
had ceased, various means were resorted to with the view of exciting uterine
contraction, but without the slightest effect, although the patient was not at
all exhausted. Finally, ergot was administered in a full dose, and within a
few minutes after this, and perhaps fifteen or twenty from the occurrence of
the last pain, a powerful contraction expelled the remainder of the child. It
was perfectly asphyxiated, there being no sign of respiration, and only one or
two throbs of the heart at a long interval; the surface blanched ; lips livid.
A large vessel of warm water was in readiness, and into this the body was
immediately plunged, and cold water immediately after dashed on the surface
with a view to excite respiration ; after a repetition of this without any suc-
cess, a blanket was spread on the floor, the child laid upon it in the prone
position, and what Dr. M. Hall terms his ready method of imitating respira-
tion at once resorted to, the surface of the body having been previously dried.
The body was first rotated gently on the side and a little further, describing
an arc of a little more than 90°, by which means all pressure was removed
from the walls of the thorax; as a consequence, a tendency to the formation
of a vacuum was produced by their elasticity, and air rushed into the lungs.
Turning the body back again to the prone position, the weight of the same,
aided by gentle pressure along the chest posteriorly from above downwards,
expelled the air from the lungs. At the same time, from the flaccidity of the
neck of the child, it was requisite, every now and then, to give an extra turn
to the head so as to bring the face downwards, and thus allow the tongue to
fall forwards and drag with it the epiglottis, thus allowing a free ingress of
air to the larynx, a point especially insisted on by M. Hall in his rules.

At first, no sign of a natural respiration was elicited, and the infant, with
its blanched, cold surface completely exposed to the air, its flaccid limbs, and
livid lips, certainly presented no very encouraging appearance to the by-
standers, by whom such apparently trivial efforts at resuscitation were doubt-
less regarded with something akin to contempt; very soon, however, as the
artificial respiratory movements went regularly on, the child gasped. At
first, these gasps occurred at long intervals, that is, after about every three
rotations, then after two; very soon, at each change of position, and then
regular respiration, but exceedingly feeble, ensued. At the same time, the
livid colour of the lips gave place to a roseate hue ; a feeble attempt to open
the eyes was noticed. This was not until artificial respiration had been kept
up for perhaps twenty-five minutes; still the artificial respiratory movements
were continued, and the natural respiration continued to improve regularly
but very gradually, and then gentle frictions over the chest and extremities

1857.] Lente, Ready Method in case of Infant born Asphyxiated. 349

with dry flannel had a perceptibly good effect, causiDg a frown and a feeble
attempt at crying. At this juncture, I concluded to try the warm bath with
a view to excite the feeble circulation, and this attempt demonstrated conclu-
sively the wisdom of Marshall Hall's imperative rule — not to excite the circu-
lation of the blood before establishing the respiration, for it was evident that
the blood had not been sufficiently aerated, as was evinced by the respiratory
movements becoming slower and feebler, and the colour of the lips changing
again to a purplish hue; artificial respiration was immediately re-established
with almost immediate effect; the child feebly opened its eyelids, and the
respiration became more regular. After about three-quarters of an hour, or
perhaps longer, from the commencement of the operation, the infant was
wrapped in a warm blanket, care being taken to leave the face and upper part
of the chest freely exposed, and not to overheat the surface — also to keep the
child on its side, lest, in its extremely feeble condition, the tongue should fall
backward, and interfere with the full establishment of respiration. Nothing-
more was done, except to watch the infant closely for the next two hours, and
occasionally to use gentle friction over the body with flannel. It was not
considered prudent to dress the child until after the lapse of six hours, at
which time it cried strongly and appeared as strong as an ordinary infant.
The child is now, ten days after birth, perfectly well and strong.

The above case is given with considerable detail for the reason that Dr.
Hall's rules and observations,1 so much commented on recently in the English

[} The accompanying wood-cut illustrates Dr. M. Hall's method: —

His directions are as follow : —

"Place the patient on his face, his arms under his head, that the tongue may fall
forward and leave the entrance into the windpipe free, and that any fluids may flow
out of the mouth ; then

1. Turn the body gradually but completely on the side, and a little more, and then
again on the face, alternately (to induce inspiration and expiration).

2. When replaced, apply pressure along the back and ribs, and then remove it (to
induce further expiration and inspiration), and proceed as before.

3. Let these measures be repeated gently, deliberately, but efficiently and perse-
veringly, sixteen times in the minute only. — Editor.]

350

Curtis, Extirpation of the Entire Clavicle.

[Oct.

journals, have received but little of that attention in our journals which their
novelty and importance demand.

Note. — Dr. Hall, at the suggestion of a friend, has called his the ready
method. Would not the, physiological method be a more scientific, and equally
appropriate term, in contradistinction to the unscientific and empirical methods
hitherto employed and still in vogue?

Art. VI. — Extirpation of the Entire Clavicle. By Charles R. S. Curtis,
M. D., Chief Surgeon to the North-western Eye Infirmary and Orthopaedic
Institution, Chicago.

Elizabeth B , aged 20, consulted me, about the 20th November, 1856,

in regard to certain tumours existing on her neck and wrist. On examination,
the tumour on her wrist was found to have a base about the size of a dollar,
of an oval shape, and projecting about half an inch above the surface. It was
situated on the anterior and internal side of the right wrist-joint, lying over
the styloid process of the radius, the scaphoid, the trapezium, and the base
of the metacarpal bone of the thumb. It was hard, almost cartilaginous,
vascular, and exceedingly sensitive — the least touch causing acute pain. It
was so firmly united to the deep tissues, that we could not determine whether
the bones were involved.

This tumour first made its appearance when she was quite a child. She
first remembers it as a small red excrescence, about the size of a pea. From
this it gradually enlarged, until about four years ago, when it had attained
the size of a hickory-nut. At this time it was excised by Dr. Cole, of Detroit.
The operation, however, did not prove successful, as the tumour immediately
began to reappear, and, at the end of a year, was again excised by the same
surgeon ; no portion of bone being removed during either of the operations. •
This operation, also, proved unsuccessful; and, about one year from the time
of its performance, she had it burnt out with caustic of some kind, by a phy-
sician of the above named city, whose name I was unable to ascertain. This,
again, was followed by a return and another removal by caustic at the expira-
tion of another year. During all this time, the base of the tumour had been
constantly growing larger, and about one year after the date of the last cau-
terization, she presented herself to me — the tumour appearing as I before
described. The lymphatic glands in the course of the arm and axilla have at
times been sore and enlarged.

About five years ago, she discovered a soreness at the middle of the sub-
cutaneous surface of the clavicle, and soon after detected a slight enlargement
at that point, which increased very slowly until within the last three months,
during which time it has been growing much more rapidly, in fact enlarging
nearly one-half. Pain has not been very great, but still there has been a
constant soreness, slightly increased on pressure, but not aggravated at night.
During the last three months, the pain and tenderness have been greatly in-
creased. On examination, I found the tumour about the size of an egg, hard
and unyielding, and exceedingly sensitive — the slightest pressure producing
great pain. The crackling sensation, spoken of by authors, I was unable to

1857.]

Curtis, Extirpation of the Entire Clavicle.

351

detect, though my friend, Dr. H. M. Kirke, thought he observed it. The
soft parts above and below the clavicle were somewhat sensitive and painful
under pressure, but not swollen. The lymphatic glands were not enlarged.

The patient was of full habit, sanguineo-ljmphatic temperament, and has
always enjoyed excellent health, with the exception of her having contracted
syphilis about the time of the first appearance of the clavicular tumour. The
syphilitic affection was entirely cured, and she has never had the slightest
evidence of constitutional impregnation since. Her mother and one sister
died of phthisis. No malignant disease is traceable in the family.

My first impression in regard to the clavicular tumour was, that it was
simply an ordinary syphilitic node. But a careful examination of the history
and general appearance of the case soon convinced me, as it did every physi-
cian who examined it, that we had a malignant disease to deal with through-
out. An operation was accordingly advised. It was deemed expedient, in
order the more effectually to secure her from a return of the disease, to remove
both tumours at one time ; and lest, by operating on the original tumour last,
we might disturb the dressings of the clavicular wound, it was determined to
dispose of that tumour first; and, accordingly on the *29th November, my
friend, Dr. Kirke (the patient being thoroughly anaesthetized) proceeded to
remove it.

The tumour was circumscribed by an incision through the healthy tissue,
and removed with the fascia that participated in the disease. It was inti-
mately connected with the deep fascia of the forearm and a small portion of
the anuular ligament ; also with the sheaths of the tendons of the flexor carpi
radialis and flexor longus pollicis. The radial artery was not divided. He-
morrhage was inconsiderable. The bones did not seem to be involved, and the
wound was allowed to heal, by granulation, under the cerate dressing.

The patient being once more brought under the influence of chloroform,
and placed on her back with the shoulders somewhat elevated, so as to depress
the head and extend the platysma myoides, I made an incision about one inch
above the clavicle, from the median line of the neck to a point a little beyond
the anterior border of the trapezius, through the skin and superficial fascia.
A second incision, parallel to this, was then made about one inch below the
clavicle of the same length. These were united by a perpendicular incision
in the form of the letter H. The flaps were now dissected back, exposing
the lower portion of the platysma myoides. This muscle was carefully divided
above and below from its clavicular attachments. It seemed to have lost its
identity immediately over the tumour, apparently from chronic inflammatory
action. The sterno-cleido mastoideus was now separated from its clavicular
origin, by shaving the bone with the point of the scalpel. The trapezius,
deltoid and pectoralis major were in a similar manner separated from the
bone. It was found that the periosteum over the extremities of the bone was
healthy, and, in order to favour the development of a useful callus, those
portions of it were allowed to remain. The bone, being accurately dissected
from its membranes at these points, an attempt was made to disarticulate it
at its sternal end. This extremity being preferred in opposition to the method
adopted by Drs. Mott and Warren, from the fact that after elevating it, in
dissecting from the cardiac side of the vessels, there would be less danger of
dividing them, and if divided, the ligature could be applied with greater
facility. It was discovered, however, that the posterior portion of the orbicu-
lar ligament could not be incised without endangering important bloodvessels,
and accordingly a different plan of procedure was adopted. About three-
quarters of an inch from its sternal extremity, the bone was cut almost through

352

Curtis, Extirpation of the Entire Clavicle.

[Oct.

by means of a Hey's saw; the soft parts being carefully protected by the
fingers of an assistant. A strong pair of bone forceps was now applied, and
the division easily completed. A piece of tape was then passed beneath, and
the bone elevated. I then proceeded to dissect the bone and tumour from
their attachments. The soft parts were somewhat adherent, and exceedingly
vascular over and around the tumour, and the blood flowed in a stream from
every incision into it. Great care was taken, during the whole operation, to
remove every portion of tissue that seemed to be in an unhealthy condition.
As the posterior portion of the tumour lay immediately over the subclavian
vessels, this dissection required, in its performance, a vast amount of caution.
But, when we had passed beyond the tumour, the difficulties and dangers
were greatly diminished ; and the disarticulation of the acromial extremity
was effected with comparative ease. But the sternal fragment was still re-
maining, and here the orbicular ligament presented some obstacles — owing to
its close proximity to important bloodvessels, together with a slight peculiarity
in that articulation — but by cautious dissection was finally divided, and the
last portion of bone removed.

Not one of the large vessels was divided, although during the latter part
of the operation the patient was restless and uneasy, from the fact that dis-
agreeable symptoms compelled us to suspend the use of the anaesthetic.
Hemorrhage was not very great, only two ligatures being required. The
flaps were brought over and united by interrupted suture and adhesive straps.
The arm and shoulder were supported by Fox's Apparatus, and the wound
dressed with tepid water. The operation and dressing required nearly three
hours. The patient was greatly exhausted, and fell asleep before the dressing
was completed, not even waking when the stitches were passed.

During the whole time I was ably assisted by distinguished medical gentle-
men of this city, and my obligations are especially due to Dr. H. M. Kirke,
Dr. Wm. Narian, Dr. J. C. Thorp, and Dr. Banks.

The patient was placed in bed and ordered the following sedative diaphoretic
mixture : R. — Liq. pot. cit., spts. mindereri, aa ^ij; aq. camph. ; morph.
acetas gr. iv; antimon. et potass, tart. gr. j. S. — A tablespoonful every hour.
But on account of the extreme sedation, it was discontinued and stimulants
given. This sedation was evidently caused by the anaesthetic, of which ,fvj
of chloroform was used. The stimulation was maintained until the evening
of the second day — an assistant remaining by the patient's side until reaction
was fully established. On the morning of the 3d December, the dressings
were removed for the first time. Owing to the extreme mobility of the part,
and the impossibility of keeping it at perfect rest, the wound, though looking
healthy and suppurating finely, presented no points of union by the first in-
tention. The stitches were removed, and the adhesive straps reapplied. The
tepid water dressing was used throughout the convalescence. On the seventh
day, she was sitting up, and the day following left her room, though she did
not leave the house until the eighteenth day, when she presented herself at
the office a mile and a half from her residence. She improved rapidly, and
on the 30th December was discharged cured. The periosteum that had been
left having thrown out considerable ossific matter ; by the aid of a shoulder
brace nearly all of the movements of the arm are accomplished, and the mem-
ber is increasing in strength daily. The humour involved the outer portion
of the sternal extremity and middle third of the clavicle, and presented every
evidence of osteo-sarcoma. Unfortunately we had not the facilities for sub-
jecting it to a microscopical examination.

1857.]

McDowell, Smallpox and its Varieties.

353

June 7, 1857. Since the preceding was written, and about two months
after cicatrization was completed, she began to complain of sharp, lancinating
pains shooting up from the wrist to the shoulder. The cicatrices began to be
sensitive with pain and tenderness on pressure. These symptoms gradually
increased until the 14th of May last, when I find the following entry in my

note-book : " Was called to see Lizzie B ; found her suffering great pain

in wrist and neck, also along sternum; great tenderness on pressure over
sternum, but no swelling. Auscultation reveals nothing unnatural. The
wrist somewhat swollen, and has, on one or two occasions, bled profusely.
The clavicular space continues to contract. Complains of choking sensations;
pain in the head ; constipation, &c. Ordered a mercurial.

"IQth. Wrist and neck the same, other symptoms much improved."

It is now apparent, and indeed has been for some time, that a reproduction
of the disease has taken place. I called on her to-day. The pain and tender-
ness have increased but little since the 14th of May. She is suffering again
with torpidity of the bowels, pain in the head, nausea, &c, which were pre-
scribed for as before.

Among the peculiarities of this case may be noted the rapid recovery
from the operation, the slow and insidious course which the disease has pur-
sued throughout, arid its unfailing reproduction.

Art. VII. — Smallpox and its Varieties. By A. W. McDowell, M. D., of
Bedminster, Somerset County, New Jersey.

The question of vaccination, and its protective powers, has much agitated
the profession. A large number contend that it ought frequently to be re-
peated. It is the duty of all of us to furnish such facts as may have fallen
under our observation, and then to let the profession judge for themselves.

Case I. — On the 20th of February, 1848, 1 was called to see James H., a
young gentleman from New York, on a visit to his relations, who reside in
the country. When I first saw him, he was complaining of a pain in his
head, and had much nausea, which he thought was owing to a foul stomach,
as riding in the cars had often affected him in such a manner. I prescribed
an emetic of antimony and ipecacuanha, which relieved some of the symptoms,
but he still complained much of his head. I left him a dose of calomel, to
betaken in the morning, to be followed by Epsom salts. When this operated^
his head seemed relieved; but as his stomach still continued much disordered/
and there was much fever, I gave him an effervescing mixture and sweet
spirits of nitre.

About the second day some vesicles began to appear upon his face and
body. They came on gradually until there was a dozen upon his face.
They were conoidal, with an inflamed border. On the second day they con-
tained a pale yellowish fluid. About the fourth day some commenced scab-
bing, and left permanent marks. They never flattened. On the ninth day
he was worse, and had secondary fever. At this time I had much chicken-
pox in my practice, and pronounced this a case of the same kind; but I was
much mistaken, as the sequel will show. It was a case of genuine varioloid.
No. LXVIIL— Oct. 1857. 24

354

McDowell, Smallpox and its Varieties.

[Oct.

Case II. — On the 17th of March I was called to see W., a young man in
the same family where the above-mentioned young man was visiting. He
also complained of his head, and called my attention to a curious eruption over
his abdomen, which smarted and itched very much. It occupied the pubic,
and extended over both iliac regions from one hip to the other; and presented
exactly the appearance of a scarlet rash. There was no eruption elsewhere
upon his body. There was no sickness of the stomach, and no pain in the
bowels; the pain was confined to the head, and there was slight fever. I
gave him an active dose of calomel and jalap; he was not confined to his bed.
On the 20th, he was walking around out of the house ; it was a raw, damp
day. In the afternoon he sent for me; he was chilly, and felt stiff in his
limbs. He still complained of his head; I gave him some antimony in solu-
tion— as much as his stomach would bear. On the 21st, continued the same
treatment ; on the night of that day he was quite flighty ; on the 22d he was
no better. I had hardly reached my home after the morning visit, when a
messenger arrived and told me that my services were again required — that the
young man was in fits I repaired to the house immediately, and found him
in convulsions, foaming at the mouth, and tossing his head incessantly from
one side of the bed to the other; subsultus tendinum, so severe that it was
only at intervals that I could judge accurately of the state of his pulse ;
constant motion of one arm or one leg; total inability to swallow; pupil of
the eye dilated, and insensible to the strongest light; breathing stertorous;
the rash had disappeared. In consultation with a neighbouring physician, we
determined that our best chance was to bleed freely if the system would
allow us. Accordingly we bolstered him up in the bed, and opened a vein.
The blood flowed freely, but was very black. After bleeding we put his feet
in warm water and ashes; he lay quiet while his feet were in the water. We
then applied mustard sinapisms. We met again in the evening, and deter-
mined to bleed again, as the pulse had risen in volume. The blood was very
dark at first, but gradually became of a lighter hue. After the first bleeding
there were no more fits, but the other symptoms continued the same. We
now commenced rubbing his spine with strong mercurial ointment. In the
morning, the patient continuing the same, we gave him three drops of croton
oil; this vomited and purged him freely; he passed his feces in the bed;
his urine also flowed involuntarily. This evening, in swabbing his mouth, a
little water trickled down, and he put up his hand and wiped it away; he also
gaped. He was still insensible. On the morning of the 24th he awoke and
spoke. He was perfectly unconscious of the interval from the morning of the
22d to the 24th ; so that he lay insensible for forty-eight hours. The rash
never returned upon his abdomen, but came out slightly upon his breast. His
memory continued weak for some weeks, but he gradually improved and got
perfectly well. He is a hearty man to the present time. It is a little singu-
lar, that a little girl, a child of this gentleman, had a similar eruption about
the knee-joint, but had no fever with it. All these patients had been vacci-
nated.

Case III. — Working for the last-mentioned gentleman, who is an exten-
sive farmer, were two black men, who with their families live in a house a
short distance from the gentleman's dwelling. The one family consisted of
the husband, wife, and four children ; the other family, of a man and his
wife. Of the children, two were vaccinated, two were not; of the other
family the wife was unprotected.

The black woman with the family washed the last shirt worn by the first

1857.]

McDowell, Smallpox and its Varieties.

355

patient. To this shirt some scabs must have adhered. After washing the
shirt in warm soapsuds, she washed her children's clothes in the same water.
The nest Sunday she put clean clothes upon the child that was unprotected,
and on the 21st this child broke out with genuine smallpox. On the 23d it
began to show its true character. This black child had never been to the
house; it caught the disease from the clothes. The other child, not having
clothes on just from that wash, did not break out at that time. In this case
the smallpox ran its ordinary course, and the patient got well.

Cases V. and VI. — In two weeks time from the commencement of the
eruption in the last-mentioned patient, two others broke out with the small-
pox— the other unprotected child and the man's wife ; I vaccinated both of
them, but without effect. They both had smallpox, and both recovered.

As they had but one room in the house for each family, the children that
were vaccinated were in the same room with those that were sick, and were
exposed to the contagion; they remained perfectly well. The mother of the
children had been vaccinated several years before ; she took care of the child-
ren ; she had a slight rash upon her, was somewhat unwell, but did not get
down. The husband of the black woman that had the smallpox was vacci-
nated twelve years before ; he took the sole care of her, and was well all the
time. On the day the first-mentioned child broke out, there was a black
woman with her child visiting there; they were both unprotected. I vacci-
nated them ; the ninth day of vaccination was the fourteenth day of exposure,
when the second patient broke out with the smallpox — (I lost a few days by
not having good vaccine virus.) But vaccination obtained the victory. She
had a few pocks and some fever, but some Epsom salts soon cured her; the
child remained well.

From these cases it can be seen that it is not necessary to vaccinate every
seven years, as some contend; and that vaccination will check smallpox, even
after exposure to the contagion, provided the virus has time to enter into the
system. In connection with these cases let me mention an experiment I tried
at this time. An elderly gentleman had been inoculated in his childhood
with smallpox ; I vaccinated him ; it took well, and ran the usual course of
vaccine virus.

Case VII. — At that time I had been vaccinated twenty-five years; it has
never taken upon me since. I was exposed to all the contagion of smallpox.
The varioloid and other patients did not affect me; but after being exposed to
smallpox at the time the last-mentioned patient broke out, it disordered my
head, giving me a very bad headache; it impaired my appetite so that I had
no inclination for food, and my tongue was furred. I took a little physic, and
in a day or two the symptoms, passed off ; at the end of two weeks these
symptoms returned again, but in a much milder form.

These cases are interesting in several particulars. The varioloid in the
first case so much resembled chicken-pox, that it was impossible to distinguish
it by the mere eruption from some of my chicken-pox patients. The varioloid
produced a singular rash in the second case. This rash never became vesicu-
lar or pustular — it was a simple rash. And yet this simple rash produced
very alarming consequences after the patient exposed himself to cold. That
varioloid, in the unprotected, produces genuine smallpox, thus showing the

356

McDowell, Smallpox and its Varieties.

[Oct.

identity between it and smallpox. And lastly, vaccination proved itself in
these cases all it has been represented — namely, if fully in the system, it
will completely preserve from the smallpox.

Case VIII. — On the 15th of December, 1848, I was called to see Mrs. F.
The history of the case is this. She had been married then two weeks. On
the day after her marriage her husband and herself went to New York on a
pleasure trip. They put up at a hotel where a person, without their know-
ledge, had died of the confluent smallpox. Her husband had been vacci-
nated ; she was unprotected. Two weeks after she had been exposed in New
York she was attacked with very severe headache, pain in the back, sick
stomach, and continued nausea; tongue much coated; breath very offensive.
The day before she was taken sick she was present at a large party given in
her honour. Her sisters spoke to her about her feverish breath. The next
day she broke out with the smallpox. There were thirty persons present at
the party, several of whom had not been vaccinated, and they were very
anxious, dreading the disease; no one took it from her at that time. Hers
was a very decided case of smallpox; under the usual treatment she recovered.
Her husband, who had been vaccinated some twelve years, was with her during
the disease ; he was never sick. Her sister-in-law helped to take care of her
(she was taken sick at her mother-in-law's house and could not be removed).
She had been vaccinated fourteen years; she also complained of headache and
pain in the back, with sick stomach. In the usual time the vesicles began to
appear upon the body; but before they had half filled they shrivelled and
dried up, and left no marks. Her mother-in-law had been vaccinated thirty
years before ; she had the same symptoms, and was quite sick for some days ;
some dozen pocks filled and scabbed. In her case the vaccination had become
deadened, and she consequently suffered more. In these cases vaccination
protected the husband, and much modified the disease in the other cases.

Just nine months from the date of her attack I attended this lady in her
confinement, when she was safely delivered of a fine girl.

Case IX. — On the 29th of June, 1854, I was called to see a young lad in
the village of P. The family, consisting of his father and mother, and
several older children, moved from New York during the month of May.
They occupied rooms in the upper part of the house. The older daughter had
caught the varioloid in New York, and they brought the complaint along
with them. They were all strangers to myself and the inhabitants. When
I was called to see the lad they gave me no information, fearing the neigh-
bours— knowing they dreaded the disease. When I saw the patient he was
drawing his breath hard, and laboured very much; face flushed, pulse slow.
There was evident congestion of the lungs ; I thought that was the nature of
the complaint. I gave him a dose of calomel, to be followed by castor oil,
and put a mustard-plaster upon his breast. The next morning I called to see
him ; I then noticed a fine rash coming out upon him. I asked his mother,
" Have you the smallpox?" " No, sir." " Have you the varioloid in the
family V- She thought they had. " What had you done with the little boy
before I saw him?" " I washed him with saleratus water." "Had he a
rash ?" She thought so. Then the disease was plain to me ; it was small-
pox. For three days after this he had constant spasms, with subsultus tendi-
num, and very flighty. The only way I could manage was to put him in a
warm bath two or three times a day, and keep cold water to his head. I also
gave him internal medicines; under this treatment the spasms subsided, and

1857.]

Bennett, Case of Successful Ovariotomy.

357

the eruption came out upon him. I had to poultice his hands and feet to
bring out the eruption upon them.

The weather was quite warm ; the lad was in the second story, directly
under the roof. When I turned the bedclothes down to look at him, a very
strong odour arose. I thought if I escaped, vaccination was a sure protection.
I did escape. I was vaccinated some thirty years before, and never since.
His mother took care of him; she had been vaccinated several years before;
she continued well. This was a malignant case, the weather was hot, the
smell great, and we were all exposed; we depended upon vaccination alone,
and that done many years ago, and that protected us.

These cases made me think that vaccination, once properly performed, is a
sure preventive. All these patients got well ; not one of the number died.
These cases made a strong impression on my own mind, and I hope they will
prove interesting and instructive to my younger brethren.

Art. VIII. — Case of Successful Ovariotomy. By Hanford N. Bennett,
M. D., of Bridgeport, Conn.

Miss Alice Bassett, aged twenty-four years, consulted me early in the
month of June of the present year, for an enlargement of the abdomen,
which she attributed to a dropsical effusion. According to her statement, she
had two years since a severe attack of measles, from which, however, she
convalesced to a perfect restoration of health. In the fall of 1856 she first
perceived, as she thought, some enlargement of the abdomen, which she then
supposed was merely an increased corpulency, but at the same time felt,
upon lying down, a peculiar sensation in the left side like the trickling of
water along the abdominal walls. About the commencement of the present
year, the development of the abdomen had become so great as to excite her
alarm, but she consulted no physician, inasmuch as she felt no inconvenience
from it, and perceived no depreciation of health with the exception of some
emaciation. The abdomen continued to enlarge up to the period at which
she consulted me, when it had attained the size and very much the form of
the full term of pregnancy. She had menstruated regularly ; the quantity
of urine was neither much increased nor diminished ; the alvine dejections
were normal. Upon examination of the abdomen, fluctuation was very dis-
tinct, but it had this peculiarity, that when in the erect posture it was more
perceptible at the superior than at the inferior part of the abdomen, and
when lying upon the back there was no appreciable difference. Upon per-
cussion the dulness was general, and no resonance could be heard in either
iliac region. Although the diagnosis was obscure, I was strongly of opinion
that the difficulty originated with tin ovarian tumour, for more than one
reason. The fluctuation was very distinct, and to my feel more superficial
than usual in ovarian dropsy, that is to say, like that of ascites, but the
obscurity of the fluctuation at the most dependent portion of the abdomen
when the patient stood erect, led me at once to suspect that I had to do
either with a multilocular cyst, the largest of the loculi being situated at the
upper part of the tumour, thereby rendering fluctuation more distinct at that

358

Bennett, Case of Successful Ovariotomy.

[Oct.

point; or with a complication of ascites with an ovarian cyst, the latter ren-
dering fluctuation indistinct in the erect posture at the inferior part of the
abdomen by falling against the anterior abdominal wall, and thus interrupt-
ing the wave. Another substantial reason was the complete absence of any
symptoms implicating any important organ of the body. The action and
sounds of the heart were normal, and there was no oedema of the inferior
extremities or of any other part; the fecal evacuations were perfectly normal
in appearance, showing a want of even any functional disturbance of the
liver; the urine was not albuminous, and, as I have before said, was neither
materially increased or diminished in quantity. I at once gave my opinion
to my patient, and informed her that the only prospect of cure was in an
operation for the removal of the tumour, at the same time advising her of
the hazards of the operation and its proportionate fatal issue, which I believed
to be about one in three.

I did not see my patient again until after three weeks had elapsed, when
I found her abdomen still more distended, fluctuation more distinct over the
entire surface, and she was beginning to exhibit more signs of constitutional
disturbance, general debility, loss of appetite, &c. I immediately deter-
mined to tap her as a means of confirming or invalidating my diagnosis. I
introduced a trocar in the usual place, and when I had drawn off twelve pints
of a tenacious fluid, thicker and more opaque than that usually found in
ascites, the stream suddenly ceased, and I could not by any manipulation
renew it, although the abdomen was not more than half reduced to its nor-
mal size. I withdrew my trocar, and could then distinctly feel a tumour in
the lower portion of the abdomen, and occupying the median line. I now
determined to operate as soon as my patient had recovered from the shock of
the tapping, and without giving her time to become more exhausted by any
increase of the effusion.

Upon the fourth day after tapping, being the third of July, I proceeded
to the operation assisted by my friend Dr. W. L. Watson, of this city, and
in the presence of several individuals, friends of the patient. I made an
incision from the umbilicus to the pubis, carefully cutting through the peri-
toneum about midway between these points, as a first exploratory opening
into the abdominal cavity. The moment the peritoneum was penetrated a
gush of fluid took place, showing that the cavity of the peritoneum was the
seat of a large effusion, but through the semi-transparent fluid I could discern
the white cyst filling the lower part of the cavity, and presenting as it lay
in situ a somewhat flattened superior convexity. I enlarged the opening in
the peritoneum to the full extent of the incision of the integuments, and
after allowing all the fluid to escape, I grasped the tumour and carefully
drew it through the opening. I first experienced some difficulty in accom-
plishing this, and began to fear there might be adhesions to the sides of the
pelvis, but upon making still stronger traction the tumour slipped through
the incision without further difficulty, the resistance having been due, as I
suppose, to the close impaction of the tumour in the pelvic cavity, and the
tenacity of the thick glutinous fluid which covered its surface. I then ter-
minated the operation in the usual way by passing a needle armed with a
double ligature through the pedicle, tying both parts firmly, and cutting away
the turnout Having carefully sponged the wound and closed it with four
sutures, not including the muscles within them, I applied adhesive straps to
the surface, and pinned a bandage around the abdomen in the same manner
as in childbed. During the operation, the patient was kept steadily though
moderately under the influence of chloroform by Dr. Watson.

1857.]

Bennett, Case of Successful Ovariotomy.

359

I should observe that the day previous to the operation, I directed my
patient to take a mild cathartic, which evacuated the intestines freely. After
the operation, as soon as she had become fully roused from the influence of
the chloroform, I administered a full dose of morphia, which had the happy
effect of lulling all pain, and during the afternoon she slept soundly for two
hours. It is sufficient to say here, that my patient has had an uninterrupted
convalescence, no untoward symptom arising to cause alarm or call for inter-
ference. I kept her bowels quiet with morphia, and drew off her urine
until the eighth day, at which time I administered a full dose of Epsom salts,
and during their operation she passed her urine voluntarily, and has con-
tinued to do so from that time. The ligatures came away on the fourteenth
day, and the cure was complete, the wound being perfectly consolidated.
Just five weeks after the operation she walked a distance of two miles with-
out more than ordinary fatigue, she has again menstruated normally, has a
strong appetite, regular alvine dejections, and says she was never in better
health.

The tumour was a multilocular cyst, assuming very nearly a globular form
after extirpation, and measured seventeen inches in circumference. The
term multilocular cyst commonly used to designate these morbid growths,
does not seem to me to describe their anatomical character, because they are
evidently not cysts with several compartments, but a congeries of cysts, one
growing within the other, and thus multiplying in some instances to an infi-
nite number, and varying in size from one capable of containing a gallon or
more of fluid, to those of only microscopic appreciation. The largest in this
tumour had not a capacity exceeding six fluidounces.

Remarks. — Notwithstanding the frequency of the operation of ovariotomy
in this country, and the success which has attended it in the hands of some
surgeons, many eminent members of the profession, and some of our first
operators, are disposed to doubt its propriety. I believe this is due in part
to the too great fear of wounding the peritoneum, and the idea of its exces-
sively inflammable character ; and in part to the failure of operations in
cases badly selected. I shall remark nothing further in reference to the first
point, except that so far as I can gather from my own experience and that of
others who are familiar with the subject, the dread of inflammation of the
peritoneum after operations involving its section, is unnecessarily great, and
that our ideas of the highly inflammable character of serous membranes are
derived from idiopathic inflammations which are generally of a diffuse cha-
racter, and consequently attended with great fatality, while experience shows
that inflammations the result of traumatic lesions have a strong tendency to
become circumscribed and to terminate favourably.

I believe the judicious selection of cases to be the chief point to be con-
sidered in reference to this operation, and first as to a diagnosis of the
tumour. It is a common opinion, and one derived from the books, that
ovarian tumours are usually situated upon the side to which the diseased ovary
belongs. Cruveilhier declares this view to be purely theoretical, and main-
tains that these tumours take the median line as soon as they attain any size,
for the reason that it is in this direction they are most easily developed.

360 Bennett, Case of Successful Ovariotomy. [Oct.

This is undoubtedly true of those cases in which the tumour is rapidly
evolved, and where its contents are of a fluid and yielding nature j tumours
of this character take their place almost immediately upon the median line,
and are generally unaccompanied by pain ; but when they are of slow growth,
of a solid character, and attended with considerable pain during the first
period of their development, they then contract adhesions to the sides of the
pelvis and to the pelvic viscera, and may for a time retain a lateral position
in the abdomen. The history of the case should be closely investigated in
reference to these points as under the latter circumstances the surgeon should
in my opinion hesitate as to an operation. If the tumour has been of rapid
growth, has early taken a position upon the median line, and has been unac-
companied by much pain, I consider the success of an operation as highly
probable, with favourable conditions of the general health of the subject;
but when the morbid growth has been slow, probably of a sarcomatous nature,
inclines to a lateral position in the abdomen, and has been accompanied by
severe pains in the pelvic region and through the hip and back, I believe the
operation generally unwarrantable, inasmuch as there will probably be en-
countered adhesions so extensive as to render it difficult, and the breaking up
of which, if possible, would insure a deadly peritonitis.

Another important point to be considered is the age of the patient. I
should always prefer to operate upon a young subject, at least not one above
forty. Ovarian tumours are developed much more rapidly, and are also more
rapidly fatal in younger females, especially where the contents of the tumour
are of a fluid character. A few months is time enough to develop a sac
sufficiently large to fill the cavity of the abdomen, and if tapping is resorted
to, the patient succumbs in a short time to the drain upon her system.
Hence I believe it to be highly important that the operation should be per-
formed before tapping, or if, as in the present instance, it is thought best to
tap in order to arrive at greater certainty as to the nature of the case, to ope-
rate before the patient has become further exhausted by an increase of the
effusion. The fact that young subjects die much sooner of this disease than
those more advanced, is to my mind a strong inducement to the operation in
such persons.

In conclusion, I consider the suggestions of my uncle, Dr. E. P. Bennett,
in reference to this operation, as highly judicious and worthy of repetition,
viz : If the patient menstruates, select the period for operating immediately
after the cessation of the menstrual flux ; evacuate the bowels freely by a
cathartic the day before the operation ; draw off the urine for several days
after, and keep the bowels quiet with opiates (in the present case I continued
this to the eighth day); keep the room as nearly as possible of an even tem-
perature; and also subdue pain and procure sleep with sufficient anodynes.

Bridgeport, Conn., Aug. 10, 1857.

1857.]

Lente, Recovery from Fracture of the Spine.

361

Art. IX. — Two Cases of Recovery from Fracture of the Spine, loith Re-
marks on this Fracture. By Frederic D. Lente, M. D., Surgeon to
the West Point Foundry.

Fracture of the spine, excluding the case of partial fracture, as where
the spinous processes merely are knocked off, is commonly regarded as neces-
sarily fatal, and, judging from the published opinions of the great authorities,
recovery from complete fracture is one of the rarest events in surgical prac-
tice. Thus, Erichsen, in his Science and Art of Surgery, says, M it is
inevitably fatal." Benj. Bell, in his System of Surgery, says: "Examples
of recovery are recorded, but they are extremely rare, and to be ascribed to
the secret operations of nature rather than to the efforts of art." Sir Charles
Bell, in his lectures on the Spine and Thigh Bone, says : " Although
many have survived such fractures for a considerable time, yet they generally
linger and die of the consequences."

Sir Astley Cooper appears not to have met with an instance of recovery
from this injury. He relates two cases where patients survived a long time,
one two years, the other nine months, but finally died of exhaustion, from
sloughing, &c. Such being the case, it is hoped that no apology will be
deemed necessary for introducing the two following cases. We give them at
length, at the risk of being considered tedious, not only on account of their
rarity, but because the favourable result seemed, in some measure at least,
due to the treatment employed, as well as to what Benjamin Bell calls the
" secret operations of nature."

Case I. — Barny McGuire, aged about forty, of ordinary health, a "helper"
in the foundry, fell a distance of twelve or fifteen feet while at work on the
9th July, 1853, striking on his back. I did not see him until about four
hours after the accident, when I found him in the following condition — he
was lying on his back in bed, his countenance pale and indicating great
anxiety and prostration, intellect perfect; pulse rather feeble; stimulants
had been already administered, was complaining of severe pain in the dorsal
region, and " numbness" in the lower extremities. Had not passed his water
since the accident. There was complete paralysis of motion in the left limb,
and almost complete in the right, being just able, with great difficulty, to
flex the knee slightly, and to " stir the toes."

Upon examining the back, the only point at which he complained of pain,
I found a considerable projection at the situation of the lower dorsal vertebrae;
upon pressing upon which, patient complained of great pain and soreness, so
that it was difiicult to make out whether it was due to extravasation or to
injury of the bones. He was immediately cupped over this point, and
directed to be kept as quiet as possible in bed. After the cupping, a little
power of motion in the right leg was gained, and he complained of a pricking
sensation in both limbs. Paralysis of sensation was evidently less. His
urine was also drawn off.

July 27. The improvement of the patient, up to this date, has been very

362

Lente, Recovery from Fracture of the Spine.

[Oct.

slight. Sensibility has been, in a great measure, regained in both limbs, but
he still complains of pains darting down them, and of the disagreeable prick-
ing which followed the cupping. It is impossible to maintain a proper tem-
perature in the feet and legs even by frictions and hot applications. He can
now flex the right thigh tolerably well, and the leg on the thigh, but cannot
raise the limb bodily from the bed, nor can he flex the foot, nor flex nor ex-
tend the toes. In the left limb but little improvement has taken place, still
there has been some. His water has been drawn off regularly three or four
times daily, and lately, it has been slightly alkaline, of an ammoniacal odour,
and a deep brown colour. If allowed to remain in the bladder longer than
six hours, patient complains terribly. He is still unable to change his posi-
tion in bed without assistance. He sometimes lies on his back, sometimes
on his side. The extravasation has now disappeared, and all doubts as to
fracture have been removed. There is a marked projection of the spinous
processes of the tenth and eleventh dorsal vertebrae, and pressure at this
point still gives pain j when patient is moved in bed he fancies he feels the
bones move upon each other ; this sensation, he invariably feels when his
position is changed. Bowels torpid, and moved regularly by enemata and
cathartics. Muscles of lower extremities considerably attenuated. Has
been taking infus. fol. buchu and acid, sulph. aromat. for the vesical diffi-
culty.

July 29. Commenced yesterday the application of electricity by means
of the rotary magneto-electric apparatus ; after two applications, patient was
enabled, with considerable pain and difficulty, to pass his water. To take a
pill composed of strychnia gr. one-twelfth, ferri sulph. gr. j, aloes Barbad. gr.
j, three times a day.

Aug. 12. Have not had occasion to use the catheter since the electricity
was commenced, though sometimes patient experiences great difficulty in
passing his water; its colour and odour have improved under the acid and
buchu, and it is less alkaline. The sensibility of the extremities has been
almost completely restored, and the pains and pricking sensations have almost
completely disappeared. The motive power is steadily improving, but very
gradually indeed. He can, with the assistance of his hands, cross the right
leg over the left, and flexion of the thigh and leg is performed with consider- -
able facility, but he is still unable to raise the limb bodily from the bed.
The improvement of the left has not kept pace with the right, but it is,
nevertheless, very apparent. The strychnia has a very obvious effect, pro-
ducing almost constant tonic spasm of the muscles, and stiffness of the knee
and ankle-joints. When intermitted for a time, the spasm soon subsides.
The bowels still inclined to be torpid.

Sept. 25. Patient has been slowly but steadily improving since last date.
The same treatment has been continued. The electricity was applied every
day for two weeks ; then every second day, and now every three days. The
pills were intermitted for some days, but patient thought he did not improve
as fast without them, and they were recommenced. He takes now one-eighth
of a grain of the strychnia twice a day, and the tonic spasm is still produced
by it to some extent. If he takes three a day, the stiffness of the joints is
such that he cannot move his limbs to any extent. Had incontinence of
urine for a few days, which was relieved by tinct. ferri muriat. and tinct.
canth. His condition is now as follows : The prominence of the spine at
the seat of injury remains the same, and forms quite a salient angle. He
can stand alone with some difficulty, if supported by a cane, and can hobble

1857.]

Lente, Recovery from Fracture of the Spine.

363

along the floor of his room slowly with the aid of a cane and crutch. Ordered
to take one pill a day, and to discontinue electricity.

March 14, 1854, eight months from the date of the accident. Patient
has been walking about the street for two or three months. His gait im-
proves very slowly. He can walk about two hundred yards without requiring
to rest. Has not been under any special medical treatment for the last four
months.

May, 1857, nearly four years from the date of the accident. Patient has
been getting regular wages in the foundry for more than two years. His
work requires him to stand on his feet part of the time and to sit part of the
time. The muscular power of the right leg is much better than that of the
left. He can stand alone on this leg, but cannot on the other. When he
mounts a flight of stairs, he always raises the right foot, and drags the other
after him ; sometimes he mounts two steps at a time. On the other hand,
the sensibility of the left leg is much greater than that of the right, but the
sensation of both is considerably impaired. He can walk for a quarter or
half a mile without resting. He cannot stand at his work without support
more than fifteen or twenty minutes at a time. Occasionally he requires to
pass his water very frequently through the day, but never involuntarily, and
does not often require to rise at night. His general health now is better
than it has been for years. No pain or pressure now at the seat of injury.
The prominence remains the same. His gait in walking is a very peculiar
one, seemingly requiring great exertion ; he seems to throw the limbs bodily
forwards from the hip-joint.

Case II. — This patient, a strong, healthy young man, aged about 20, an
apprentice to a tinman, was stepping from the roof of a house to a narrow
scaffolding below, when he lost his balance; finding that he was about to
pitch head foremost to the ground, a distance of about thirty feet, he sprang
forward, and alighted first on his feet, and then received the force of the con-
cussion on his seat. The ground was firmly packed clay and gravel, yet the
force was so great that his buttock made a distinct depression. He was taken
up pale, exceedingly prostrated, and almost senseless ; he soon, however, re-
covered to some extent. It was found immediately that he was completely
helpless below the hips, and he was taken home on a cart.

Upon a thorough examination of the patient, after having him placed on a
bed, and after reaction had set in, there was found to be complete paralysis
of motion of both lower extremities. Paralysis of sensation was complete, on
the right side, from a little below the crest of the ilium downwards; on the
left side, the paralysis of sensation was not so complete. Paralysis of the
bladder complete. Upon pressing along the spine, no pain was complained
of until the lumbar region was reached; at about the middle of this, the
tenderness was very great, but there was no perceptible irregularity. The
patient remained under my care for about two weeks, and was then removed
on a litter to Orange County, where his parents reside; for the further his-
tory of the case, and its treatment, I am indebted to the kindness of his
physician, Dr. J. H. Thompson, of G-oshen, whose own language I shall pre-
serve, as far as possible, in continuing the case.

"When he first came under my care, in October, 1853" (that of Dr.
Thompson), "he was entirely helpless; he had not the slightest power of
motion in either limb for at least three months after the injury." Paralysis
of sensation was complete on the right side below the hip-joint; on the left
side, sensation was much impaired, but not obliterated. The catheter was

364

Lente, Recovery from Fracture of the Spine.

[Oct.

required for five months regularly ; there was a good deal of pain complained
of at the seat of injury; indeed, all his suffering was referred to this point;
upon the slightest motion being given to his body, or on the slightest pres-
sure, this suffering was much increased, he had not power to move himself in
any degree.

"At first, it may be remarked, the question to be decided, with respect to
the case, was as to whether there was total destruction of the spinal cord, or
some injury less serious. I must acknowledge to you, from what I know of
the history of the case, the nature of the accident, and the condition of the
patient, I apprehended, in the beginning, that the employment of remedies
with a view of even partial cure of the paralysis would be discouraging in-
deed. The very slight motion, however, at the end of several months from
the receipt of the injury, perceptible though slight, stimulated my hitherto
feeble hope in reference to improvement, and encouraged a perseverance in
appropriate remedies to that end."

"With regard to treatment, I used externally embrocations of various kinds
to the seat of injury, and once, a blister was applied. Subsequently, to
relieve the spinal irritation, which undoubtedly existed at first, a seton was
introduced ; also a strychnia plaster combining a counter-irritant." The in-
ternal medication consisted in " strychnia, in doses of one-twelfth of a grain
from the first, which was continued at least one year. He began with two
pills a day of the dose I have mentioned, gradually increasing to three or four
a day, according to the effect. Indeed, at one time, he hazarded as many as
six and even seven a day. This he did on his own responsibility, and T need
hardly state, with alarming consequences; however, he subsequently took five
of these pills a day with advantage. After he had taken the strychnia about
a year, it was alternated with pulv. nux vomic. in doses of one-fortieth of a
grain with good effect, taking two pills of the strych. and two of the powders
daily. After continuing the remedy for a year and a half, it seemed to fail
to produce any marked effect. Strychnia and nux vomica were the sheet
anchor in the treatment, and its success exceeded my most sanguine expecta-
tions. Electricity was also employed, but, I fancy, without benefit." With
regard to the progress of the improvement of muscular power : " In the be-
ginning, that is between three and four months after the accident, it was
hardly perceptible, and improved gradually, and very slowly of course. It
was first observed in the right foot, that in which the paralysis of sensation
was complete."1

"Patient had a very bad bed- sore in the early part of -his illness, occasioning
some sloughing of the soft parts, and necrosis of the bone. This difficulty
caused considerable trouble; exfoliation occurred, and finally the wound filled
with healthy granulations, and cicatrized; it was apparently the last lumbar
vertebra."

The following is the patient's own account of his case in a letter to me,
dated Eeb. 26, 1857 : "I was confined to the bed seven months; then I
commenced sitting up a little every day; I commenced standing on my feet
(with support), and walking around the room with two chairs in eight months.
It was eighteen months before I used the crutches, or rather the contrivances
I had when you saw me. I could use my right limb so as to bend it in the
knee in four months. I could pass my water without assistance in five

1 I have had to draw up the case from letters written at various times by Dr.
Thompson, in answer to questions from me, which will explain its somewhat discon-
nected character.

1857.]

Lente; Recovery from Fracture of the Spine.

865

months. I bave no trouble about it now. I have never any painful sensa-
tions, except in my right limb, the one I have the most use of. The sensa-
tion consists in a quick, sharp, pain, principally in the knee, which comes in
and goes out very quickly ; I can see it draw my foot up in the ankle, but I
cannot feel it there. In that limb (the right), I cannot feel it if I stick a pin
anywhere below the hip-joint. In the other limb (left), I have nearly the
natural feeling; have never had any pain in that limb. I can bend the limbs
in the knee, thigh, and hip-joints. I can bend the right nearly as well as any
person. I cannot quite stand alone. I do not think that I have gained any
in the last year; have used no remedies the past year."

When I last saw my patient, as he states, all improvement had ceased for
a year, and probably forever. He was then driving about the country in a
wagon by himself, selling books, prints, &c, and walking about when occa-
sion required.* His contrivance, referred to in the above letter, for assisting
locomotion, is ingenious, and much more useful, in such a case, than ordinary
crutches. It consists of two stout walking canes, terminated above by a cross-
piece for the hand, and below by a broad thick shoe or piece of plank about 6
by 12. He first puts one forward, then swings forward the leg, then places
the other in advance, and then swings forward the other leg, and so on. He
flexes his knees but slightly in walking, and throws out his legs with a swing-
ing motion from the hip-joint. Patient's virility is not impaired; general
health as good as ever. Dr. Thompson lays considerable stress on the
patient's "unprecedented hopefulness and courage," under the most dis-
couraging circumstances, as conducing, iu no small degree, to the favourable
result which ensued.

There are several notable features in the above cases, upon which it may
not be out of place briefly to remark. The fact that, in both cases, the mus-
cular power was greatest in the limb having the least sensibility, in one no
sensibility at all; the long continued use of mix vomica and its alkaloid, and
its undoubted efficacy in both cases, is a feature also worth noting. I believe
so decided evidence of the good effect of this agent in paralysis from injury
has seldom been observed or recorded. The most important point, however,
is the recovery of two cases of complete fracture of the spine, whether this
result be attributed to the treatment at all, or to the powers of nature, in re-
sisting and repairing the effect of severe injury, or to both. This is a point of
considerable practical importance. Complete fracture of the spinal column
has almost universally been regarded by authorities, as will be seen by the
references at the beginning of this article, as necessarily fatal. In conse-
quence of this, no special efforts are usually made with a view of curing
or partially curing the case, or of prolonging life until the recuperative
power of the system may step in, and assist us in alleviating at least the
wretched condition of the patient. How do patients usually die with this in-
jury? It is generally by exhaustion of the vital power caused, in a great
measure, by the constitutional irritation and debility consequent upon the
terrible bed-sores and the subacute inflammation of the mucous coat of the
bladder, due, probably, to the irritating effect of decomposed urine, and even
of healthy urine on the surface of an organ deprived of its wonted nervous

366 Lente, Recovery from Fracture of the Spine. [Oct.

supply. The only chance then for the patient consists in warding off, as far
as possible, these contingencies by the most assiduous attention. In many
cases, no doubt in a vast majority of cases, we shall fail to do so, even with
the aid of water beds, and all the other appliances which modern ingenuity
and humanity have devised ; but these two cases, especially the last, where
long continued paralysis of the bladder, and a bed-sore, involving caries and
exfoliation of bone, did not preclude a partial recovery, and' without any
special or expensive appliances for promoting the comfort of the patient, prove
that, occasionally at least, we may succeed, and should encourage a steady
perseverance in all the minutige of treatment which may tend, in the slightest
degree, to facilitate so desirable a result. A frequent catheterism and a scru-
pulous attention to the cleanliness of the patient, and protection from pressure,
of those parts of the body which come in contact with the bed, form the prin-
cipal prophylactics ; while strychnine, both endermically and internally, and
balsam of copaiba or buchu, where inflammation of the bladder is threatened,
should be perseveringly employed.

The manner in which fracture of the spine usually occurs, or rather the me-
chanism of the fracture, if I may so express it, should also encourage a more
hopeful prognosis in these cases. In most cases, according to the dissections
which I have made and seen in fatal accidents of this kind, the fractured ver-
tebra is crushed between those adjacent to it, and sometimes diminished to
almost one third its natural thickness in front; just as if the force had been
applied in a directly 'vertical manner, as it was in J ones' case, but as it is not
generally. Sometimes, as in a specimen in my collection, the fragments of
the body of the bone are forced backward, so as almost completely to close up
the vertebral canal, but it may not be diminished but little, as in another spe-
cimen in my possession j in an occasional case, perhaps not at all, as the frag-
ments happen to be forced in a different- direction, or as the injury is less
extensive. This, no doubt, happened in McGruire's case, although the crush-
ing of the vertebra must have been very great from the amount of deformity
still existing.

Note. — Just after concluding this article, I chanced to meet Mr. Jones, and
have learned some additional particulars of interest concerning his case. His
condition is just the same as it was when he last communicated with me by
letter in February. He has no power whatever iu the flexors or extensors of
the feet, or in any of the muscles of the feet, consequently, they hang help-
less and useless. The muscles of the thighs and legs are very much atten-
uated, not more so, however, than they were a year ago. He states that he
never walks over eight or ten rods at a time ; if he attempts to do more, he
gets very much fatigued; he is able, however, to get into his wagon which
is low, and to go about from place to place alone. He also states that, for
some months after the accident, there was great rigidity of the knee and hip-
joints, and it was with great difficulty, and considerable pain that they could
be flexed, but forced flexion and passive motion were kept up by himself and

1857.]

Smith, Poisoning by Chloroform.

367

friends, together with frictions, with great perseverance for about a year before
the rigidity was entirely overcome. He thinks that it was only by these
constant efforts on the part of himself and friends for so long a time, that he
was enabled to overcome the difficulty, and to gain what muscular power he
now possesses, aided, of course, by the medical treatment.
Cold Spring, N. Y., Aug. 14, 1857.

Art. X. — Poisoning by Chloroform. By Charles H. Smith, M. D., Assist-
ant Surgeon, U. S. A. (Communicated by Thos. Lawson, M. D., Surgeon-
General, U. S. A.)

Private Henry Thompson, Company F., Second Cavalry, having a few
days previously made an ineffectual attempt to destroy himself, which resulted
in a slight wound ; on April 13, to carry out his design, swallowed (it appears
from his after statement) nearly two ounces of chloroform. I saw him at
10 J P.M., ten or fifteen minutes after he had taken the poison. An empty
vial lying near had evidently contained chloroform, of which substance his
breath smelled strongly. He had already vomited, but could not be roused
from insensibility ; breathing stertorous, pulse about 60. After an ineffectual
attempt to administer an emetic, the stomach pump was used, and a pint and
a half of warm water was twice injected into the stomach, and twice pumped
out, loaded with the fumes of chloroform. Spirits of ammonia, fjij, were
introduced into the stomach before the withdrawal of the tube. After re-
moving the tube vomiting occurred, but the pulse became more feeble,
breathing slow ; eyes insensible to light. The effect of the cold douche on
the head was tried for a few minutes with seeming advantage, the pulse
growing stronger, but falling again, the application was discontinued. The
surface becoming cold, he was wrapped in five or six blankets, a large stimu-
lating enema administered, and resort had to mustard cataplasms. For the
next hour (between 12 P. M. and 1 A. M.) the symptoms were more un-
favourable ; respiration very slow and feeble ; face purple ; pulse reduced to
about 40, feeble, sometimes scarcely discernible, and intermittent. He evi-
dently grew worse.

At 1 o'clock a gradual improvement commenced, and by 2 A. M. the
respiration was easy, pulse 60, feeble but regular; insensibility continues,
from which he did not recover till 5 A. M.

April 14. At 8 A. M. pulse 98, burning thirst; tongue coated; fauces
red; pain in the stomach, which rejects everything. Says the vial (a two
ounce one) was nearly full. Blister to epigastrium. There having been no -
operation from the bowels, sulph. magnes. ^j was administered, but vomited.
Enema, ol. terebinth, ^ss, and ol. ricini Jij, in a large quantity of warm

368

Smith, Poisoning by Chloroform.

[Oct.

water, brought away large stools. In the evening, milk was rejected by the
stomach, likewise tr. opii gtt. xxx.

15th. Did not sleep ; incessant short hacking cough; pain in the throat
continues; pain is felt in the whole abdomen; tongue dry and thickly
coated; stomach retains cold water but rejected ol. ricini ^j. An enema
caused several stools. Warm fomentations applied to abdomen, and at bed-
time ext. hyoscyami gr. iij to be given.

16th. Passed restless night; pain in the region of the liver; jaundice
appearing; pulse 110; skin hot and dry; expectoration somewhat rusty; no
crepitation in lungs, but respiration harsb behind. Mass. hydrarg. gr. x ;
half dozen cups over region of pain. Tea and toast and milk were relished ;
several operations from the bowels during the day; jaundice increased by
evening. Ext. hyoscyami gr. iij at bedtime.

17th. Pulse 96; skin soft and moist; pain in throat and over liver dis-
appeared, and feels much better ; conjunctiva and skin very yellow. Tartrate
of soda and potash ss.

18th. Slept well; pulse 70, soft and natural; continues to improve; jaun-
dice decreasing.

After this, in consequence of pain in the right shoulder and region of liver
at different times, cups and blisters were applied over the liver, and mercurials
administered. By the last of the month he was well, and only waited, to be
returned to duty, for the healing of the slight gun-shot wound.

Fort Mason, Texas, May 1, 1857.

1857 ] Hutchinson, Disease incident to Pregnancy, etc.

369

FISKE FUND PRIZE ESSAY.

Art. XI. — What are the Causes and Nature of that Disease incident to Preg-
nancy and Lactation, characterized by Inflammation and Ulceration of
the Mouth and Fauces, usually accompanied by Anorexia, Emaciation, and
Diarrhoea ; and what is the best mode of treatment? By David Hutchin-
son, M. D., of Mooresville, Morgan County, Ind. The Dissertation to
■which the Fiske Fund Prize was awarded, June 3d, 1857. 1 (Published
by request of the Rhode Island Medical Society.)

That a disease of this character has of late years existed to a great extent,
especially in the Western States, and has excited considerable interest among
physicians, is evident from the frequent notices taken of it by Western
journals. But it is not a disease of recent origin. Marshall Hall has ad-
mirably described some of its symptoms. Abercrombie, in his inimitable
work on the stomach and bowels, details a case, which, from the description,
appears to have been of this character. In the lectures of Stokes and Bell,
it is stjled stomatitis nutricum ; in Wood's Practice, nursing sore-mouth;
and more recently by journal writers, stomatitis materna. Dr. E. Hale gave
a description of it, to the Boston Medical Society, in 1830, and Dr. Bakus in
the American Journal of the Medical Sciences in 1841. Since that time,
several short essays on the disease have appeared in the medical journals of
the United States. The disease has become more frequent, more closely ob-
served, and better understood; but the literature of the subject is, as yet,
scanty. Dr. Shields, of New Albany, Indiana, makes the statement (on the
authority of the editor of the American Journal of the Medical Sciences),
that neither the late Dr. Dewees, of Philadelphia, nor any of the physicians
of that city, had ever seen a case of it, but that it was observed by Dr. A.
Clapp, of New Albany, as far back as 1825; thus confirming the statement
that the disease prevails more in some localities than others. That it is not
peculiar to this country is evident from the writings of Abercrombie. That

1 The Trustees of the Fiske Fund, at the annual meeting of the Ehode Island
Medical Society, held at Providence, June 3, 1857, announced that they had awarded
to the author of the dissertation bearing the motto —

" Wheat from the fields of science, and cockles from my own farm"
the premium of one hundred dollars, by them offered for the best dissertation on the
following subjects, -viz: "What are the Causes and Nature of that Disease incident to
Pregnancy and Lactation, characterized by inflammation and Ulceration of the Mouth
and Fauces ; usually accompanied by Anorexia, Emaciation, and Diarrhoea; and what
is the best mode of treatment V

And upon breaking the seal of the accompanying packet they learned that the suc-
cessful competitor was David Hutchinson, M. D., of Mooresville, Morgan County,
Indiana.

Isaac Eat, M. D., Providence,
Jas. H. Eldridge, M. D., E. Greenwich,
Chas. W. Parsons, M. D., Providence,

Trustees.

S. Aug. Arnold, M. D., Secretary of the Fiske Fund.
No. LXVIIL— Oct. 1857. 25

370

Hutchinson, Disease incident to Pregnancy, etc.

[Oct.

we may answer the first question propounded, " What are the causes and
nature of this affection, incident to pregnancy and lactation V we will first
point out the symptoms and course of the disease, together with the anatomi-
cal lesions discovered by post-mortem examinations.

Although it is conceded by all writers on this disease that the affection of the
mouth is only symptomatic of a previous pathological condition of the general
system, yet the affection of the mouth is usually the first symptom that awakens
the patient's attention. It generally comes on very suddenly, and, although
she may have previously suffered from anorexia and various gastric disturb-
ances, yet neither the physician's nor patient's attention is attracted to her
condition till after the buccal symptoms ensue.

Dr. Byford (American Journal of the Medical Sciences') makes three va-
rieties of this disease, taking the affection of the mouth as the basis of his
division. These varieties differ from each other only in grade or severity;
all pointing to the condition of the general system and the intensity of the
disease. The affection of the mouth is but a part of the many forms that this
protean disease assumes, for, as we shall see in the sequel, the disease is
migratory, and spends its force on all the mucous surfaces. It is therefore
most appropriate to treat of it according to its intensity or grade, and divide
it into the acute and subacute or chronic forms.

The acute form generally makes its appearance either immediately before or
shortly after delivery; the subacute some weeks or months afterwards. In both
forms various gastric derangements, such as acid eructations, pyrosis, costive-
ness, alternating with diarrhoea, generally precede the affection of the mouth.
In the acute form, the mouth affection generally begins with a scalding sensa-
tion, extending from the mouth down the oesophagus to the stomach, accompa-
nied by a profuse discharge of hot burning saliva, difficult and painful deglu-
tition ; warm and hot fluids cannot be borne; there is loss of appetite and taste ;
tenseness and increased frequency of pulse ; tongue red around the edges, and
in patches on the dorsum. The redness speedily spreads throughout the
whole cavity of the mouth and fauces. The parts are of a scarlet red colour,
but as a general thing, not much, if at all swollen. This appearance may be
of transient duration, lasting only probably for a few hours, more generally
for several days, when it disappears, to be again removed in a very short-
time. But more generally, with this diffuse inflammation, the inside of the
cheeks, gums, and under part of the tongue become covered with a crop of
aphthae or vesicles, which burst and become ulcers. The duration of this
crop of vesicles and ulcers is generally about eight or ten days, and some-
times longer, when they will frequently disappear, to be succeeded by another
crop of vesicles and ulcers as distressing as the former. In some cases the
whole force of the attack is concentrated on the tongue, either on its side or
under part; and begins from an inflamed point, or a fissure, or the bursting
of a vesicle, which rapidly ulcerates, and spends its whole force on the one
part, until the tongue becomes almost half amputated by a ragged notch.
.Suddenly this ulceration ceases^ the cavity granulates, fills up, and heals; but
the organ is left distorted. The whole force of the paroxysm is concentrated
on this one point ; the constitution suffers less than when the ulcers are more
numerous and diffused over the buccal cavity. The disease would seem to
have located itself, and its consequences are less to be feared, for when the
stomatitis is more general, the inflammation is more disposed to extend itself
along the adjacent mucous surfaces to all the neighbouring cavities. We
have seen it travel from the mouth down through the pharynx and oesophagus
to the stomach, thence through the alimentary canal its whole length ; most

1857.]

Hutchinson, Disease incident to Pregnancy, etc.

371

usually* locating itself in the colon, and spending its force on that extensive
mucous surface, and frequently destroying the patient by ulceration of its
coats. Again we have in several instances known it pass through the larynx,
trachea, and into the bronchia, and either establish inflammation in some
portion of these tubes, or awaken into action disease of the lungs. It some-
times follows the nasal passages into the different cavities of the skull and
maxillary antrum, and there induces permanent infianimatiou ; or it may
pass through the Eustachian tube to the tympanum, and thence to the mas-
toid cells. Dr. Byford states that he had seen a case where permanent deaf-
ness of one ear, and exfoliation of bone occurred. It also attacks the mucous
surfaces of the vagina. Dr. Brainard had seen cases in which ulcerations of
the vagina, alternated with diarrhoea. I have also observed cases in which
ulcers of the mouth alternated with diarrhoea and vaginal ulcerations. In-
deed, there is not a mucous surface but is liable to be attacked with this
ubiquitous inflammation.

In addition to the local symptoms presented by the mouth, fauces, &c,
derangement of the digestive aud assimilating organs claims our first and
earliest attention. As before remarked, the affection of the mouth is usually
the first symptom that awakens the patient's attention; but nevertheless, de-
rangement of the stomach and bowels always exists for some time prior to the
occurrence of the buccal symptoms. I have invariably found that the greater
the gastric derangements, the more extensive and difficult to heal were the
ulcerations of the mouth. For weeks — it may be for months — before any
affection of the mouth supervenes, the patient is much troubled with flatulent
and acid eructations. She has a sinking feeling, a sensation of weakness at
the epigastrium, or else a burning and feeling of distension, which requires
her to loosen her dress to relieve the epigastric uneasiness. She also has
slight febrile irritation, especially in the evening, with increased tenseness
and frequency of the pulse. An acid fluid is generated in the stomach, and
it would appear that everything the patient eats takes on the fermentative
process; occasionally vomiting occurs; the bowels are either confined or too
loose, and we would readily infer that the patient laboured under dyspepsia
in one of its many protean forms.

Accompanying these symptoms are those presented by the condition of
the urine and urinary organs. I found, on questioning my patients, that
before the accession of a paroxysm, either of the sore-mouth or diarrhoea, that
they laboured under painful and difficult micturition, which at times became
distressing, and prevented sleep at night. They would pass only small quan-
tities of urine at a time, not more than a tablespoonful or two, which gene-
rally attracted their attention from the highness of its colour, and amount of
the deposit it threw down on standing Sometimes this condition of the urine
and urinary organs exists for several days before the accession of a paroxysm
either of the sore-mouth or diarrhoea; for let it be borne in mind, that when
diarrhoea ensues there is but little inflammation of the mouth ; and again,
when the mouth becomes inflamed, the bowels are generally confined. And
I always found that the urinary difficulty was in a proportionate ratio to the
intensity of the paroxysm either of the diarrhoea or sore-mouth.

I have examined the urine chemically aud with the microscope in quite a
number of cases. The following conditions were universally present: —

1. It is highly acid, instantly changing blue test paper to a deep red.

2. It is above the normal specific gravity, varying from 1024 to 1030.

3. The deposit thrown down on standing is urate of ammonia, and urate
of soda, as revealed by frequent microscopic examinations in every case that

372

Hutchinson, Disease incident to Pregnancy, etc.

[Oct.

came under my care. In one case, a lady at the sixth month of utero-gesta-
tion applied to me for the painful and scanty micturition. She had the sore-
mouth in a previous pregnancy and lactations, in a very severe form. She
again had tenderness of the mouth and gums, and slight redness of the
tongue, and occasionally diarrhoea. She said that she knew that the sore-
mouth was about to come on from the urinary difficulty. She described the
urine as passing only in small quantities, very red, and containing a copious
sediment. I procured four ounces of the urine, which was very acid, and of
high specific gravity, 1030. Under the microscope the figures of urate of
ammonia, in the globular form, were very numerous but very small. There
were also uriniferous tubules and epithelial cells. Dr. Lockhart, a very re-
spectable neighbouring practitioner, and likewise a microscopist, had a number
of cases under his care. He examined the urine in seven cases, and his ob-
servations correspond with my own. In all at some stage of the disease
severe pain was felt in passing water, doubtless on account of an excess of
acid (uric acid or its salts, urate of ammonia or urate of soda) ; such being
the fact in the cases tested. In one of his cases the disease persisted for
eight months, and, during the latter part of the term of her sickness, albumen
was found in the urine in connection with epithelial cells, altered blood glo-
bules, and uriniferous tubules.

To prove the correctness of the microscopical observations, I subjected the
urine to the test of heat, and when it reached the boiling point the sediment
was dissolved, and smelled ammoniacal; thus proving that the deposit con-
sisted of urate of ammonia.

Among the formidable array of symptoms which attended this affection,
none is more distressing than the diarrhoea, which rapidly exhausts the pa-
tient, and produces emaciation, so that she becomes of a pale earthy colour.
The discharges from the bowels are generally liquid, and in cases that persist
for any length of time, mucus is often present; and when the case is about
to terminate fatally, they are frequently tinged with blood. There are also
colic pains and tenderness of the abdomen in cases of this description.

In the subacute form the patient is not troubled with so much intestinal
disorder; she loses flesh and strength; the countenance becomes pallid; one
or two ulcers are generally found about the mouth and tongue; there is a*
peculiar sense of weakness at the epigastrium ; the bowels are usually costive,
and although she suffers from flatulence and indigestion, yet the appetite re-
mains tolerably good. We have known this form to persist during the whole
period of lactation, and the patient still attend to her household duties.

Anatomical Lesions. — In the few dissections that have been made of pa-
tients that have died of this affection, ulcerations of the mucous membrane of
the intestinal canal have existed in every case. Dr. Hubbard, of Ashtabula
County, Ohio, saw at a post-mortem of a well-marked case, five ulcers, with-
out any other morbid appearance to account for the fatal result. The buccal
aphthae preceded by several months the diarrhoea of which the patient died.
The ulcers were circular, about three lines in diameter, indurated, and very
deep. Three of them were situated in the colon, and two in the ilium; the
surrounding surfaces were healthy, or nearly so. In the Transactions of the
Indiana State Medical Society for 1856, Dr. McLean relates the post-mortem
of a case in which the mouth and fauces were entirely denuded of their mu-
cous coat, with numerous patches of ulceration extending throughout the
oesophagus. The stomach was also almost completely denuded of its mucous
coat, with numerous patches of ulceration extending deep into its muscular
tissue. A small space around the pyloric orifice was the only healthy por-

1857.]

Hutchinson, Disease incident to Pregnancy, etc.

373

tion. The duodenum was healthy. There were a few inflammatory patches
in the colon. The bladder had traces of inflammation around its neck; and
a few patches of ulceration existed in the vagina.

The following morbid appearances were found in a case which for a series
of years was under my observation: In January, 1851, the patient was at-
tacked, two weeks before delivery, with this affection, in a very severe form.
Under treatment it disappeared, and was renewed a few days after confine-
ment. It disappeared again, and was renewed afresh in two more weeks.
The discharge of saliva was very profuse, the ulcers in the mouth numerous.
She had hectic and night-sweats, and sank very low ; doubts were entertained
of her recovery, but under a tonic treatment she did recover, and continued
to nurse her babe. She became again pregnant, and during pregnancy was
threatened with the disease. She again used a tonic and nutritive treatment,
which was continued during the latter months of gestation; and although
there were frequently symptoms of the disease, yet by the treatment it was
kept in subjection, and she continued to nurse her child. In 1854 she was
again pregnant, and suffered from indigestion and stomach derangements.
About the sixth month diarrhoea came on, which persisted in despite of judi-
cious treatment, and she died three months after delivery, the case terminat-
ing fatally by convulsions.

I have been thus particular in the narration of the case on account of the
extensive local lesions.

The autopsy was made seventeen hours after death.

The peritoneum exhibited evidences of inflammation; general appearance
pink colour; bloodvessels of injected.

Adhesion of pancreas, throughout their whole extent to duodenum.

Structure of kidneys softened, congested, and pus in pelvis of; greatest
quantity in right one.

In ureters, traces of inflammation one and a half inch in extent.

Want of integrity of colon; mucous membrane wanting in many places,
the ulcerative process being so complete.

Caecum as colon ; small intestines and stomach for the most part normal.

Spleen completely softened, but for its serous covering would barely hold
together; small collections of pus throughout its interior.

Liver enlarged; softened in the inferior portion of the right lobe, which
was also congested, and showed signs of recent inflammation. A melanotic
tumour, three-fourths of an inch in diameter, was found on its convex sur-
face. Gall-bladder filled with black grumous material, about a gill in quan-
tity. Weight of liver four pounds aud two ounces.

In this case the patient was never free of the disease since the first attack
in 1851, and although in the last illness the mouth was but little affected,
yet it was evident that it was the same affection that had located itself in the
colon ; for whenever the diarrhoea would cease a few days, the buccal symp-
toms would appear.

Causes and Nature of. — The causes may be divided into two kinds, extrin-
sic and intrinsic, or remote and proximate.

1st. Extrinsic Causes. — Dr. Dunglison makes the remark that the disease
prevails more in some localities than others. There are many practitioners
that have never seen a case of it, while others have frequently had to contend
with its intractable character. The disease is either of recent origin, or it
has, to a great extent, escaped the observation of our predecessors ; at least,
during the last few years, it has attracted the attention of the profession. In
some localities, it has been almost endemic among pregnant and nursing

374

Hutchinson, Disease incident to Pregnancy, etc.

[Oct.

females. Why is it that, during the last few years, it should have become
more frequent ? It was rarely seen in the Western States until after the ap-
pearance of dysentery and diarrhoea, in 1849, '50, '1, % '3 and '4. Dur-
ing the ten years preceding 1849 but two cases, of a mild character, came
under my observation. After the appearance of dysentery, the affection be-
came more common. Indeed I found, in many instances, the affection of the
mouth associated with dysenteric symptoms. In those years there existed an
epidemic constitution of atmosphere, producing a proclivity to disease of the
mucous membranes. Indeed, during those years aphthous stomatitis was not
an unfrequent accompaniment of dysentery in its latter stages; and in several
instances cancrum oris supervened in children. Hence we infer that an epi-
demic constitution of atmosphere, producing a proclivity to disease of the
mucous membranes, especially of the intestinal canal, is one of the extrinsic
causes of this affection, peculiar to pregnancy and lactation. Since dysentery
and other diseases of the digestive tube have been less frequent, we have
seldom seen this affection, and during the last two years have been rarely
called to treat it. Its prevailing more in some localities than others may be
attributable to surrounding circumstances, as the quality of the soil, bodies of
stagnant water, &c. Dysentery and diarrhoea have prevailed more in some
localities than others, and as we have marked a coincidence in the prevalence
of the two affections, we may attribute their prevailing in particular localities
to similar causes. We are, however, fully convinced that the malaria that
produces remittent and intermittent fevers is not a cause of this disease; for,
when remittents and intermittents prevail, this affection is hardly ever seen.

2d. Intrinsic Causes. — These are to be sought for in the diathesis and con-
stitution of the patient, and in the changes produced on the system by the
functions of gestation and lactation. Those that are usually attacked with
this affection are of a feeble, delicate constitution, and have previously suf-
fered from debilitating causes, such as hemorrhages, leucorrhcea, and are
generally either of the scrofulous or tubercular constitution, and labour under
debility and ansemia. Young women of this constitution are frequently the
subjects of it in the first pregnancy ; and I have observed that frequent
pregnancies and lactations are the most common sources of this affection.
The most inveterate case that I have ever seen, the autopsy of which was.
given in the preceding part of the essay, gave birth to eleven mature children
in seventeen years. Stomatitis, in a severe form, appeared with the ninth
child, and her system never recovered from its consequences.

Youth may be regarded as a cause. Doctor Lockhart has given me some
interesting statistics on this point. In twelve of his cases, the disease ap-
peared in four at the third child, the ages of the mothers being respectively
24, 26, 22, 23. In six with the first child; ages 17, 20, 22, 20, 21. In
two with the fourth child; ages of each 25. The cases reported by Brainard,
in the Northwestern Medical and Surgical Journal, were all young women.
My own cases were young females that procreated rapidly, and whose consti-
tutions were illy adapted to the task of utero-gestation and lactation.

Another intrinsic cause is the changes effected in the system by gestation
and lactation.

Dr. Wood says that the cause of this disease is some influence exerted on
the system by the advanced state of pregnancy and lactation ; what is the
nature of this influence is unknown. Although pregnancy cannot be said to
be a pathological condition, yet in certain constitutions that are inadequate to
support the demands that are made on the system by that function, we find
more or less general derangement ensues, which is produced by the new pro-

1857.]

Hutchinson, Disease incident to Pregnane!/, etc.

375

cess of development that is going on in the gravid uterus. In the early
stages of pregnancy, the stomach sympathizes with the gravid uterus. Nau-
sea and vomiting ensue, which deprive the female of sufficient nourishment
for her own system. Depraved appetite is a frequent accompaniment. The
sensibility of the nutritive functions are changed, she emaciates and becomes
thin, the blood becomes impoverished, and it is more than probable that the
blood impoverishment is the source of the disease, the unknown influence of
which Dr. "Wood speaks. Andral and Gavarret analyzed the blood of thirty-
four pregnant women. In thirty-two of the cases they found the red globules
below the healthy mean standard, in six of which they ranged from 120 to
125 in 1000, and in twenty-six from 95 to 120. They also found that for
the first six months the fibrin was below the natural quantity, varying from 1.9
to 2.9, while during the last three months it exceeded it, varying from 2.9 to
4.8, and averaging nearly 4. Becquerel and Rodier analyzed the blood of
nine pregnant women, viz. : one at the fourth month, five at five months and
a half, one at six, and one at seven months. The maxima, minima, and mean
results are given in the following table, copied from Simon's Ghemistry : —

Mean.

Max.

Min.

Density of denominated blood

. 1051.5

1055.1

1046.2

Density of serum

. 1025.5

1026.8

1023.6

Water .....

. 801.6

Fibrin

3.50

2.5

Albumen

66.1

68.8

62.4

Blood corpuscles

. 111.8

127.1

87.7

Extractive matter and salts

6.6

8 7

4.7

Fat . . . .

1.922

2.519

1.158

Consisting of serolin

. variable

0.108

0.018

Phosphorized fat

0.646

0.863

0.381

Cholesterine ....

0.061

0.225

0.030

Saponified fat .

1.195

1.323

0.737

'he salts in 1000 parts of blood consisted of

Chloride of sodium .

3.2

3.9

2 3

Other soluble salts

! 2.4

2.8

1.8

Phosphates ....

0 425

0.690

0 282

Iron

0.449

0.490

0.370

From these analyses they conclude that pregnancy exercises a marked in-
fluence on the composition of the blood. The density both of the defibrinated
blood and of the serum is diminished, the water and the phosphorized fat1 are
increased, while the corpuscles and albumen are diminished, thus showing
that pregnancy impoverishes the blood.

Mr. West says that during pregnancy, even in a healthy woman, certain
changes in the blood (a diminution of its red particles, and an increase of its
watery elements) are of constant occurrence ) while, in some instances, those
changes are so considerable as to give rise to disorder of the general health,
precisely similar in all its characters to chlorosis. The growth of the womb,
the development of the foetus are, indeed, accomplished, for they are subject
to a law not easily broken through; but they are accomplished at the ex-
pense of the woman's constitution, and leave her often incapable of suckling
her infant, and probably liable to all that class of inflammatory affections, the
remote cause of which (as, for instance, phlegmasia dolens) is to be sought
for in the blood. M. Cazeaux, who has patiently examined this condition of

1 Phosphorized fat is always abundant in impoverished blood.

376

Hutchinson, Disease incident to Pregnancy, etc.

[Oct.

pregnancy, says that hydraemia or serous polyaemia is the most frequent
cause of the functional disturbances that take place in pregnancy, and which
are usually attributed to plethora, the analyses of the blood of pregnant
women exhibiting a diminution of globules and an increase of water, differing
only from chlorosis by containing an increased quantity of fibrin. And he
further remarks that the functional disturbances of pregnancy resemble those
of chlorosis, and that the effect of treatment confirms this view ; that it is
from the employment of iron and animal food that real benefit is obtained.
M. Jacquemier, who has paid considerable attention to this subject, states
that all the analogy that exists between chlorosis and pregnancy is that, after
the middle period of pregnancy, women exhibit the commencement of anaemia ;
and from the examination of the blood of two hundred women in the eighth
and ninth months of pregnancy, he found a diminution of the corpuscles, but
not to the same extent as in chlorosis. And, among many hundred women
auscultated at the Maternite, he only met with the carotid souffle in two or
three. Andral says that when the corpuscles are below 80 in the 1000 that
the bruit de sovfflet is a constant phenomenon. It is often heard when their
cipher oscillates between 80 and 100, and becomes more rare when the phy-
siological mean is approached, and when it is reached ceases altogether. Mr.
Williams says that the bruit de sovfflet is often present in pregnant women,
and corresponds with the frequent diminution of the red corpuscles in them.
Other authorities might be cited to show the altered condition of the blood in
pregnancy, amongst whom is Tyler Smith. Indeed, it is a fact well esta-
blished that the red corpuscles are diminished and the fibrin increased. The
buffy coat of the blood of pregnant females is a fact familiar to every one, and
hence there exists a condition of blood in pregnancy which renders the system
liable to inflammations; and we infer that this condition of blood induced by
pregnancy is the intrinsic fountain of this disease incident to pregnancy and
lactation.

Another probable intrinsic cause from our observations, is disease of the
spleen. The most intractable cases that we have seen had this accompani-
ment. Disease of the spleen produces a cachectic condition of system, not
unfrequently accompanied with ulceration of the mouth. In one of our cases
the affection of the mouth, which alternated with diarrhoea, persisted till after
the subsidence of the splenic affection.

Pathology and Nature. — At an early period of pregnancy, the stomach
sympathizes with the gravid uterus; the new function that the uterus has to
perform in the development of the foetus, through its nervous connection with
the stomach, produces various sympathetic disturbances of the latter organ.
Nausea, vomiting, diarrhoea, anorexia, acidity of stomach, and pyrosis, are
the frequent results of these extensive sympathies. Hence nutrition be-
comes imperfect, and consequently there is a diminution of the nutritive
materials that supply the blood to repair the waste of the tissues. An almost
poisonous influence (says Tyler Smyth) seems to be exerted by the gravid
uterus in some constitutions, consequently the blood becomes impoverished
from the impaired nutrition produced by the deranged digestive organs. And
when we consider that the subjects of this affection have at best but feeble
digestive organs, the chyle globules must be imperfect, and consequently the
blood globules imperfect. We hence see that the function of nutrition is
inadequate to the demands of the system ; more especially as there is a new
function to perform by the blood, not only in the nourishment and develop-
ment of the foetus, but that of the uterus and appendages also. In the unim-
pregnated state the uterus is a very small organ, while during the period of

1857.] Hutchinson, Disease incident to Pregnancy, etc.

377

utero-gestation it attains to an astonishing size, its capacity being increased a
little more than 519 times, and its solid substance in the ratio of twelve to
one; its bloodvessels are much enlarged, and many vessels that previously
were impervious to red blood, now circulate it freely. For the development
of the foetus, uterus, and appendages, a heavy draught is made on the blood,
especially in the latter months, when the increase of the foetus, uterus, and
appendages is much more rapid than in the early months of utero-gestation.
There exists of necessity an increased consumption of red corpuscles and an
increase of fibrin from the metamorphosis that is going on in the uterus.
Simon, in his chemistry of man, gives us some interesting facts on this sub-
ject. He says that Denis made an analysis of the blood of the mother and
of the foetus; he found that of the foetus richer in solid constituents and in
blood-corpuscles than that of the mother. The corpuscles in the blood of
the mother were 139 parts in the 1000, while of the foetus 222; also the
quantity of iron was greater in the blood of the foetus than of the mother, the
proportion being in the ratio of 1 to 2.5. Also the mass of the blood of the
foetus increases in a very rapid ratio with its development, the proportion of
corpuscles is greater, and the quantity of water less, than at any subsequent
period of life ; and for some time after birth the proportion of corpuscles and
of iron is above the ordinary standard. The facts, to a great extent, ac-
count for the blood impoverishment, and also for the fact that always attends
cases of this affection, that the children of females who suffer from it are
generally large, and what might be called well nourished. We thus infer
that there exists a disproportionate ratio between the demands that are made
on the blood by the function of utero-gestation and the nourishment of the
system to supply those demands. After parturition, the drain on the already
impoverished blood is kept up by lactation. And here again we find that
the researches of Simon and other chemists throw much light on the influence
of lactation on the female system. From their analyses we find that the
solid constituents of woman's milk range from a third to one-fourth per cent,
of the whole fluid; the salts having iron in their composition, besides butter,
casein, and sugar of milk. We further find that the solid constituents of
milk increase with the increasing age of the child. Simon gives fourteen
analyses of the milk of one woman, made from the 31st of August to the 4th
of January, a space of a little over four months, during which time the solid
constituents of milk varied from 86 to 1.38, 6, the highest amount of solid
constituents being on the 31st of December, and the lowest on the 11th of
November. It is however to be remarked, that the solid constituents of
the milk must and do vary with the quality and quantity of the food taken
by the mother. We have always found that in this affection of pregnancy
and lactation, that the lacteal secretion is abundant and of rich quality ; and
the infants, from their size and plumpness, gave evidence of such being the
case. Hence, we infer that the impoverished state of blood produced by
pregnancy is continued by lactation. We are therefore led to regard this
affection of pregnancy and lactation as an inflammation — sui generis — of the
mucous surfaces, produced and continued by an impoverished condition of
the blood; which inflammation takes on the ulcerative process, the previously
imperfectly nourished tissues presenting but feeble resistance to the ravages
of the inflammation. We find in this disease a similar condition of blood to
that which occurs in other inflammations, such as acute rheumatism, phleg-
masia dolens, and other diseases as tuberculosis, &c, viz: a diminution of
blood-corpuscles, and an increase of fibrin. We might cite numerous autho-
rities to establish this point. M. Paget shows the similarity in appearance

Hutchinson, Disease incident to Pregnancy, etc.

[Oct.

in the red blood cells, in acute rheumatism, and in pregnancy. In short, the
chemical constituents of the blood in pregnancy are such as is known to
exist in many inflammations. Rokitansky speaks of an aphthous variety of
fibrinous crasis of the blood, which gives rise to the exudations of muguet,
diphtheritis, some dysenteries, and of hospital gangrene.

The fibrinous condition of the blood exciting the inflammation, and conse-
quent ulceration of the tissues of the mucous surfaces, and the diminished
red corpuscles determining the character of the inflammation attendant on
this affection incident to pregnancy and lactation. The influence of treatment
bears us out in this view j the condition of the urine is to the same point ;
its specific gravity is above the normal standard, and loaded with waters,
showing that a great waste of the tissues is going on. All these changes
are in accordance with what we know of some inflammations. Hence, by
the changes in the blood we account for its migratory character. It is a well
known pathological fact, that there exists a blood crasis in all diseases of a
migratory character, although our means of research may as yet be insuffi-
cient to determine in what that crasis consists. Rheumatism is migratory, so
is erysipelas. The researches of modern pathologists tend to establish their
nature as consisting in the presence of a morbid principle in the blood. An-
dral and G-avarret, in their researches, show that the blood in rheumatism
differs but little in the relation of corpuscles to fibrin from that of pregnancy;
and from their analyses we find the same pathological relation of the corpus-
cles and fibrin in erysipelas. The course and symptoms of this disease inci-
dent to pregnancy and lactation, point to a blood err sis. Why else should it
attack all the mucous surfaces in alternate succession ? We have seen it
suddenly make its appearance in the mouth, and as suddenly disappear and
attack the mucous surfaces of the»intestinal canal and vagina. Is it not more
than probable that the aphthge which appear in the mouth and intestiual
canal, and degenerate into ulcers, and keep up diarrhoea, &c, may be a
fibrinous exudation occasioned by the fibrinous condition of the blood. The
influence of treatment brings us to such a conclusion, as we shall see in the
sequel, that those remedies that decrease the fibrin of the blood are the most
beneficial in this peculiar affection.

Recapitulation of the Views adcanced. — 1. Imperfect nutrition of the sys- •
tem, occasioned by the disturbed condition of the digestive organs, produced
by sympathy with the gravid uterus.

2. An altered state of the blood, produced by pregnancy, and kept up by
lactation. This condition of the blood being such as is known to exist in
inflammations.

3. Its migratory character is dependent on the condition of the blood.

Diagnosis. — This affection may be distinguished from other forms of sto-
matitis by a burning sensation in the mouth, as if it had been scalded, which
is greatly aggravated by hot drinks; attended at first with redness of the
mouth and tongue, and followed by aphthae and ulcerations of the buccal
cavity. In some cases there is a diffused redness of the mucous membrane
of the mouth, instead of ulcers. These symptoms are generally attended,
and of* en preceded by a burning sensation in the stomach, pyrosis, indiges-
tion, and occasionally vomiting. The bowels are either constipated, or obsti-
nate diarrhoea attends. The disease is confined to pregnancy and lactation,
although it has been said to attack those that were not in those conditions,
and even the male subject; yet we have seen it in no other conditions but
those of pregnancy and lactation, and would infer that it had been confounded
with some other form of stomatitis. In addition to the foregoing symptoms,

1857.]

Hutchinson, Disease incident to Pregnancy, etc.

379

its migratory character is highly diagnostic, and also the frequent and painful
micturition which frequently precedes the affection of the mouth or diarrhoea.

Prognosis. — Always uncertain as to the final result. Although there is
generally not any immediate indications of danger, yet such is the liability of
the mucous structures to inflammation that the condition of the patient may
always be considered precarious while the disease persists. When the disease
extends to the larynx, trachea, or bronchial tubes, the patient may either die
from the intensity of the inflammation, or at a remote period consumption
ensues, usually in one or two years. But the patient is more apt to perish
from the intestinal affection ; when the diarrhoea persists, in despite of judicious
treatment, and the discharges are mucous, tinged with blood, indicating ulcer-
ation of the bowels, a fatal result may be anticipated. In the subacute form,
when the inflammation is confined to the mouth, and the patient measurably
retains her strength, a favourable result may be expected. As a result of our
observation but few recover a good state of health, unless they cease from the
fuDctioDs of utero-gestation and lactation.

Treatment. — From the views advanced of the pathology and nature of this
disease, the indications of treatment are the following : —

1st. To correct and improve the digestive organs, and restore them to their
normal functions.

2d. To correct the inflammatory condition of the system by supplying the
blood with such nutriment and medicines as will augment the blood-corpuscles
and decrease the fibrin.

3d. To remove the causes.

4th. To prevent the secondary affections, viz : the extension of the disease
to those organs important to the continuance of life.

Indication 1st. For the fulfilment of the first indication we are possessed of
a variety of means, some of which we will find adapted to the circumstances
of the various cases as they may present themselves. As before remarked,
we find that the greatest number of cases labour under acid eructations, gas-
tric derangements, pyrosis, burning at the epigastrium, and either constipation
or diarrhoea. To correct the acid condition of stomach, antacids and alkalies
produce the most favourable influence ; among the best of these is the bicar-
bonate of soda, which neutralizes the acid of the stomach, and at the same
time the excess of acid in the urine. It may be frequently given during the
day, either before or immediately after meals. In some cases I have found
liquor calcis answer equally as well ; it produces quite a soothing influence on
the stomach and bowels given in the dose of a tablespoonful three or four times
a day. Half a drachm of liquor potassas, given in two or three tablespoonfuls
of infusion of cascarilla bark, is also an admirable prescription, not only to
correct the acid condition of the stomach, but also to improve its digestive
powers. We have also used the bicarbonate of potass with good effects; it is
especially useful when the bowels are constipated, from its laxative qualities.
Alkalies answer the twofold purpose of neutralizing the acid condition of the
stomach, and at the same time the acid state of the urine. The urine becomes
more copious and clear after their use, and a diminution of the gastric dis-
turbances and an evident improvement of the mouth usually follows. Alka-
lies are particularly valuable when the bowels are confined, but when diarrhoea
ensues they have to be used with caution. They correct the acid state of the
stomach temporarily, but do not prevent the generation of acid in the sto-
mach. Consequently we must resort to such remedies as will prevent the
secretion of acid by the stomach. For this purpose the vegetable and mineral
astringents are the most efficient. Such as kino, logwood, catechu, krame-

380

Hutchinson, Disease incident to Pregnancy, etc.

[Oct.

ria, and bismuth, &c, all of which diminish the secretions of the stomach and
intestinal canal. We have found the most beneficial effects from logwood,
krameria and bismuth, an infusion of an ounce of logwood and a drachm of
cinnamon in ten ounces of water and strained, of which from one to two
ounces may be given for a dose before meals. We have tried kino and krame-
ria, but prefer the logwood; patients take it more readily than either of the
others, and its astringency is nearly the same. But to improve the digestive
powers of the stomach, nothing is equal to the trisnitrate of bismuth in com-
bination with an antacid. It not only soothes the mucous membrane of the sto-
mach, probably by sheathing it from the acid generated by the stomach, but
it also produces an anaesthetic effect on the sentient nerves of the stomach,
which, in the indigestion that accompanies this affection, seem to be in a state
of exalted sensibility. Bismuth restrains the secretions of the stomach, and
also of the intestinal canal; it may be combined with columba powder with
an admirable effect. Astringents are not only valuable in restraining the acid
secretions of the stomach, which give rise to many unpleasant sensations in
this affection, but they also serve to prevent the occurrence of that intractable
form of diarrhoea that is so frequently an accompaniment of this disease.

Diarrhoea. — But few cases escape diarrhoea; the patient may have costive
bowels one day and diarrhoea the next. The diarrhoea is but a transference
of the disease from the mouth to the intestines; the acid condition of the
stomach and intestinal canal producing irritation of the mucous membrane,
inflammation, and an aphthous condition of the mucous follicles is easily set
up, which terminates in ulceration. Dr. Hubbard, of Ohio, regards the dis-
ease as essentially ulceration of the mucous follicles, and relates seven cases
in which the following treatment was eminently successful : R. — Sulph. zinc,
pulv. ipecac, aa9j; pulv. mastiches 9ij; terebinth, canadens.q.s. — M. Ft. mass
pilul. in 60 dividend. The sulph. zinc, in the recipe is the only one of much
medicinal value, the other articles rendering the pill insoluble till the zinc
can reach the diseased follicles. Abercrombie cured his case, after a great
variety of treatment, with a decoction of logwood. Byford has used with
benefit the vinous tincture of golden seal (liydrastatis canadensis'). Sulph. of
alum and borax has also been used with benefit. We have found trisnitrate
of bismuth and pil. plumb, acetas et opii of more efficacy in controlling the-
diarrhoea than any other remedies. We have used all the astringents, tannin,
gallic acid, persesquinitrate of iron, with more or less benefit, but none have
succeeded so well with us as the bismuth and pill of plumb, acetas et opii.
The bismuth may be given in doses from five grains to a drachm, as often as
may be thought necessary, according to the severity of the case. It is best
adapted to those cases in which the diarrhoea is persistent, but moderate.
How it acts is rather speculative, but it is probably by its tonic power on the
exhalants of the intestines. There probably exists a loss of power of the ter-
minal capillary membrane, resulting from the impoverished condition of blood
failing to nourish the tissues of the system normally; consequently exos-
mosis of the fluids is easily produced. It likewise produces a tonic influence
on the ulcerated mucous follicles. It has been known, when scattered on
languid granulations on the cutaneous surface, to restore them to a firm and
healthy character. It is perfectly insoluble, and in passing through the bowels
comes in contact with the ulcerated patches, and thus produces a local astrin-
gent, combined with a tonic influence. It is most efficacious given in the
dose of twenty grains three or four times a day, and that quantity may be
given every two hours. It generally requires several days to insure the good
effects of the remedy, but when its effects are produced they are more perma-

1857.] Hutchinson, Disease incident to Pregnancy, etc.

381

nent than from any other article. In cases in which the diarrhoea is copious,
and seems to rapidly exhaust the patient, the pil. plumb, acetas et opii is
more prompt than bismuth, especially when the stools contain mucus tinged
with blood. The acetate of lead also restrains the secretions of the stomach
and intestinal canal, and assists in cutting off one source of the diarrhoea. The
pil. plumb acetas et opii may be given in the dose of three grs. plumb, acet.
to one-fourth gr. of opium every two, four or six hours, according to circum-
stances. During the continuance of diarrhoea, the patient ought to maintain
the horizontal position, and abstain from every kind of food that may disagree
with the stomach and bowels.

Indication 2d. To correct the inflammatory condition of the blood by intro-
ducing into the system such remedies as will increase the corpuscles and
diminish the fibrin, bloodletting has long been a remedy for inflammation, but
in this affection it is wholly inadmissible, unless under peculiar circumstances.
In cases with tense full pulse, extreme pain in the mouth and jaws, bloodlet-
ting in one instance was productive of great comfort to the patient, but
nothing but the severity of the pain ought to induce the practitioner to bleed.
When the bowels are confined and aperients are required, none has proved so
valuable as the saline. Salines lessen the acidity of the urine and decrease
the fibrin of the blood, and it will be found that the inflammation of the mu-
cous membranes are less when the urine approaches to the normal state.
There exists, then, less acid in the stomach, and consequently one source of
irritation is cut off. Of the salines, none has proved so valuable as the tar-
trate of potass and soda (the common Rochelle salts); it not only acts mildly
as an aperient, but produces a rapid effect on the acidity of the urine. Ac-
cording to the researches of Bence Jones, 120 grs. of dry tartrate of potass,
dissolved in four ounces of distilled water, will render the Wne alkaline in
thirty-five minutes.

Salines also dissolve the fibrin of the blood, and thus render it less inflam-
matory, and act as antiphlogistics; especially the salts of potash are antiphlo-
gistic by dissolving fibrin. They excite the secretions, especially of the kid-
neys, and thus eliminate the morbid materials from the blood. The iodide of
potass, which is a favourite remedy with many, acts on the same principle as
an eliminator. It is, however, better adapted to the subacute or chronic
form than the acute. Salines thus act as haematics or blood restoratives in
this affection, and are more admissible than any other antiphlogistics.

To increase the blood-corpuscles and decrease the fibrin, cod-liver oil is of
the first importance. To Professor Evans, of Chicago, belongs the merit of
having applied this remedy to nursing sore-mouth. In the Northwestern
Medical and Surgical Journal for 1853, he says that, " observing the influ-
ence of cod-liver oil in preventing the wasting of the tissues of the body in
cases of marasmus, especially from phthisis and tabes mesenterica, it occurred
to me that it might be equally beneficial in the disease in question. I have
accordingly been in the habit of giving it in French brandy or malt liquor, as
might be best suited to the taste or most convenient, and generally with the
happiest effects. When the patient can be induced to continue its free use,
it has generally proved beneficial, and, in most instances, effected a cure."
Dr. Byford also speaks in terms of confidence in relation to the curative pro-
perties of cod-liver oil in this affection, and says that it must be persevered in
during the whole term of lactation, and as long afterward as any trace of the
disease remains. This remedy has the advantage of any other tonic and
alterative from its soothing effects on the bowels. A case that came under my
care was cured by the oil, bismuth, and bicarbonate of soda, after resisting

382

Hutchinson, Disease incident to Pregnancy, etc.

[Oct.

for weeks every other treatment. The patient was reduced low, and was un-
able to turn herself in bed. The improvement was evident from the com-
mencement of the cod-liver oil treatment. It is frequently difficult to get the
patient to persevere in the use of the cod-liver oil ; the stomach will frequently
revolt at it. To obviate this, it is exceedingly necessary to pay strict atten-
tion to keep up its powers by some mild tonic and antacid, either the tincture
of gentian and bicarbonate of soda, or an infusion of cascarilla bark and liquor
potassas. Alkalies are useful adjuvants to the cod-liver oil, promoting its ab-
sorption into the blood ; for it is essentially necessary that the oil be absorbed
to produce its beneficial influence in changing the chemical constitution of the
blood. The digestive powers in this affection are too feeble to elaborate suf-
ficient fatty materials from the food to unite with the albuminous part of the
chyme, to form healthy chyle globules, which subsequently become blood
globules. Hence, the introduction of cod-liver oil into the system accom-
plishes what the weakened powers of. the stomach were not able to do. Ex-
periment has established the fact beyond a doubt that cod-liver oil increases
the blood-corpuscles and decreases the fibrin. Dr. Snow, by his analysis,
shows that the corpuscles are increased by cod-liver oil taken into the system.
Also Simon, by his analysis of the blood of those using cod-liver oil, records
an increase of blood-corpuscles and a decrease of fibrin, although from their
analysis it appears to increase the blood-corpuscles in a greater proportionate
ratio than it decreases the fibrin. Again, cod-liver oil, by increasing the
blood-corpuscles and bringing the blood to a healthy condition, the various
secretions and excretions from the blood will approximate nearer to a healthy
state; and consequently the solid contents of the urine will be lessened when
they were previously in excess. An example of this effect of cod-liver oil is
well illustrated in the disease diabetes, in which the specific gravity of the
urine is very high, from 1040 to 1060. In this disease cod-liver oil has been
found to daily and increasingly diminish its specific gravity. We found the
specific gravity of the urine high in this form of stomatitis. And if the
opinion of Sherer be correct, that the colouring matter of urine is decayed
blood-corpuscles, we must consequently see that cod-liver oil is adapted in
more respects than one to this peculiar affection. But whatever may be its
peculiar modus operandi, experience abundantly testifies to the fact that it is-
of essential value in this disease, peculiar to gestation and lactation. I gene-
rally give it in the dose of a tablespoonful three times a day, an hour or two
after meals. Some take it best in brandy, others in the compound tincture
of cardamoms, according to the taste of the patient.

The ferruginous preparations, from their well known quality of enriching
the blood with red corpuscles, and from their adaptation to some cases of
feeble and impaired digestion, would seem to be very applicable to this dis-
ease. Doctor Bakus used a combination of the carbonate, rhei, aloes, and
ipecacuanha, in the form of pills. Doctor Byford uses the carbonate in the
following manner: Take carb. potass., sulph. ferri, aa 5^ss> gum acacia
mucilage ^iv j pulverize the potash and dissolve in the mucilage, then pul-
verize and add the sulph. ferri, mix in an earthen mortar. Dose half an
ounce three times a day, gradually increasing it to as much as the stomach
will bear. He uses this only when there is no diarrhoea. I have found iron
more valuable as a prophylactic, to prevent a recurrence of the disease, than
as a curative agent during its continuance. Its action is too slow to be of
much value during a paroxysm of this affection, but when used in conjunc-
tion with cod-liver oil for a length of time, its effects are very certain and
permanent. In one case in which the disease made its appearance in the lat-

1857.] Hutchinson, Disease incident to Pregnancy, etc.

383

ter months of utero-gestation, I gave the protocarbonate of iron (Vallet's mass)
and cod-liver oil, with the effect of entirely preventing a recurrence of the
disease during lactation. The protocarbonate is a salt of iron that speedily
finds access into the blood, and is quicker in its influence than the carbonate,
which is nearly insoluble. Quevenne's iron by hydrogen is also well adapted
to this condition. But when the tenderness of the mouth will admit, the
syrup of the iodide is the quickest and the most efficient preparation. Iron,
to be useful, must, like cod-liver oil, be persevered in for a considerable length
of time, and the patient ought to be informed that unless she persevere with
the remedies she need not expect relief. As a prophylactic, iron ought to be
given so soon as the patient becomes pallid and begins to exhibit symptoms of
anaemia. The sulphate of quinia is also a valuable tonic in this affection, in
the dose of three grains twice or three times a day. It imparts power to the
nervous energies of the system, promotes digestion, and exercises a controlling
influence on the febrile irritation. When diarrhoea exists, I have found
small doses of strychnia, combined with sulphate of quinia, of much value
as a tonic, it «xercising a controlling influence over the diarrhoea.

Local applications to the mouth have been found to be only temporary in
their influence, and consequently of but little benefit in this affection. Nitrate
of silver, hydrochloric acid, and various astringents have been used with but
transient relief to the mouth. Even if the ulcers did heal under their use,
another crop of vesicles soon appeared as bad as the former. Some practi-
tioners have spoken very highly of the Hydropiper punctatum, with which I
have had no experience, and presume that its beneficial influence, like all
other local applications, is of but transient duration. So far as my experience
extends, the best local applications have been nitrate of silver and dilute
hydrochloric acid. I have found advantage from removing all carious teeth
and salivary calculi from the mouth. Vitiated saliva from unhealthy teeth
and gums passing into the stomach assists in keeping up the gastritic disturb-
ances, to which patients with this disease are so liable.

Indication 3d To remove the causes. — A change of location has been
known to result in a restoration to health, and ought to be advised when
practicable. The weaning of the child has been advised by all who have writ-
ten on this affection. When a wet nurse can be obtained, it is safest for the
patient to cease from the function of lactation. Although it may seem re-
pugnant to the feelings of the mother to deprive her of the pleasure of nursing
her offspring, yet it becomes imperative when the disease persists in despite
of judicious treatment. Although the children of patients with this affection
are generally large, and apparently well nourished, yet when the disease per-
sists for a length of time, they begin to droop and generally fall victims to
bowel affections. To ascertain the cause of this bowel affection of children, I
submitted the milk of one of my patients to several microscopic examinations,,
and although these examinations were not sufficiently numerous to advance
any facts worthy of attention, yet I found that after the children began to de-
teriorate in health the milk, in addition to the healthy milk globules, had
another globule, resembling in appearance the inflammatory globule of Gluge.
I mention this as worthy of further investigation, and as bearing on the point
whether it is not better for both mother and child that the mother should
cease nursing. Although the cessation of lactation does not always cure, yet
it puts an end to the drain on the mother's already impoverished blood ; and
thus, by cutting off one of the sources of disease, remedies are permitted to
produce their beneficial influence without the interference of a counteracting

384

Hutchinson, Disease incident to Pregnancy, etc.

[Oct.

influence existing in the system at the same time. Hence it is best, in cases
of any gravity, to advise the cessation of lactation.

Indication 4:th. To prevent and counteract the secondary affections, or, in
other words, the extension of the disease to organs important to the continuance
of life. — To fulfil this indication the patient ought to be watched with the
most sedulous attention ; and so soon as either disease of the respiratory
organs or of the alimentary canal manifest themselves, every effort ought to
be made to counteract them, the treatment for which will be the same as that
of other inflammations of these organs, bearing in mind the already impaired
condition of the system. To prevent the supervention of phthisis pulmonalis,
the most frequent sequel of this affection incident to pregnancy and lactation,
a continuance in the use of cod-liver oil is advisable, even after the disease, to
all appearance, has entirely subsided, together with strict attention to the
digestive faculties, exercise in the open air, and an avoidance of all depressing
causes.

In bringing to a conclusion an essay on a disease which has but of late
attracted attention, and on which but little has been written, it may add to
its value (if value it has) to append some illustrative cases, drawn from read-
ing and observation. The first case I find on record is one by Abercrombie,
in his invaluable work on the stomach and bowels. It is the 155th case,
page 365, 2d edition, and is as follows : —

" A lady, aged 30, came under my care in the spring of 1830, affected in
the following manner : She had a remarkable tenderness on the inside of the
lips, the tongue, and the throat ; a constant discharge of saliva, a burning
uneasiness of the tongue, throat, breast, and stomach, and great uneasiness in
swallowing, and for some time after it. She had a constant tendency to diar-
rhoea, and a feeling as if food did not remain in the stomach, but passed im-
mediately through the bowels. There was some cough, with frequent pulse,
great debility, and increasing emaciation. The throat appeared raw and a
little inflamed, the edges of the tongue and the inside of the under lip were
excoriated, and covered with small ulcers having inflamed margins. There
was also a painful excoriation about the anus and the labia. The complaint
was of three months' standing, and had begun while she was in the puerperal,
state in England. A variety of treatment had been employed without bene-
fit; she became emaciated to the greatest degree; the diarrhoea became in-
cessant, with much pain, and a feeling as if everything passed through her
immediately. She had no relief but from large opiates, and that relief was
but slight and temporary. When the case appeared to be hopeless, she began
to take a decoction of logwood, one oz. to one lb. of water, a wineglassful four
times a day, combined with a small opiate. From this time she recovered
daily, and in two or three weeks was in perfect health/'

This case shows the general character of this disease. It attacked the mu-
cous membrane of the mouth, air-passages, stomach, and intestines, even to
the extremity of the anus, and also the labia.

Doctor Brainard's cases also go to show the general effects of this affection.
The following is one of his cases, which he describes as ulcerations of the
vagina during lactation : —

" A woman, aged 35 years, had been affected for a long time with pain in
the back, hips, &c, fcr which various remedies had been used without effect.
On inquiry, he found the symptoms dated from the period of lactation, and
were attended with debility. On examination, several minute points were
seen about the orifice of the vagina, scarcely perceptible to the eye, but which,

1857.]

Hutchinson, Disease incident to Pregnancy, etc.

385

when the surface was touched with a solution of lunar caustic, turned white,
revealing the existence of numerous ulcerated points. The appearance of
minute red points upon the mucous surface, of a pale colour, he had seen in
other cases, and they are well calculated to deceive, unless a solution of
nitrate of silver, of about twenty grains to the ounce, is passed over the sur-
face." He adds : " It were easy to add to these cases others, where the
ulceration of the mouth alternated with diarrhoea, indicating a transfer of the
ulceration from the intestinal mucous membrane to that of the mouth, and
vice versa."

The following cases occurred under my own care; one the subacute form
of the disease, and the other the acute : —

Case I. — Mrs. "W., while nursing her first child, had ulcers on the sides
of the tongue; mouth very tender; child three months old, and was labour-
ing under dysentery in a mild form ; the dysenteric symptoms were relieved
in a few days, after which she was placed on iodide of potass five grains three
times a day, when the ulcers began to heal, and by a continuance in the
remedy for a month she was entirely relieved, and continued to nurse her
child. Frequent cases of a similar character came under my care, and were
relieved by similar treatment.

The following is a case of the acute form : —

Case II. — In 1851, a lady that had the disease in the subacute form in a
previous nursing ; this time she had suffered much during the latter months
of utero-gestation from gastric derangement, acid eructations, and costiveness,
alternating with diarrhoea, scanty, high-coloured urine, with a frequent dis-
position to urinate, which was attended with smarting and burning sensations.
While in this condition she was attacked two weeks before delivery with a
scalding sensation in the mouth, extending down the oesophagus to the sto-
mach, a profuse discharge of hot burning saliva, loss of appetite and of taste,
tongue very red around the edges, and in patches on the dorsum. On the
second day of her illness the pain in the jaws became distractiDg and intolera-
ble; discharge of hot saliva from mouth very profuse; pulse full and tense;
bowels constipated; urinary secretion very scanty. Twenty ounces of blood
were abstracted from the arm, which gave her great comfort by relieving the
intolerable pain in the mouth and jaws. She was given a saline draught,
which brought away very dark fetid evacuations, and reduced the inflamma-
tory condition of system. The inside of the cheeks, gums, edges, and under
parts of the tongue became covered with small ulcers, with a red, fiery surface
around them. Nitrate of silver, and also hydrochloric acid, as a lotion, were
applied to the ulcers without any apparent beneficial effects. She also took
iodide of potass for several days without benefit. The stomach continued
deranged, acid eructations, and a hot burning sensation at the epigastrium.
The iodide potass was laid aside, and she was given an ounce of aqua calcis.
three times a day, and saline aperients (tartrate potass and soda) to keep the
bowels soluble, which corrected the state of the stomach; the urinary secretion
became more abundant ; and by the application of the nitrate of silver as a
lotion, the ulcers began to heal, and the mouth speedily improved. A few
days after delivery, the sore-mouth returned; the tongue assumed the same
aspect as before ; ulcers formed on its sides and under part, and on the inside
of the cheeks; a febrile condition of system, of a hectic character, existed;
much gastric derangement, acid eructations, and burning of the epigastrium ;
coated tongue, impaired appetite, and scanty, high coloured urine, with pain-
ful micturition. The urine, on standing a few hours, threw down a copious
No. LXYIIL— Oct. 1857. 26

386

Hutchinson, Disease incident to Pregnancy, etc.

[Oct.

precipitate. She was again given saline aperients (tartrate of potass and
soda), aqua calcis, and the lotion of nitrate of silver to the ulcers. After five
days' treatment the state of the stomach and bowels became corrected, and
the state of the mouth again began to rapidly improve; and here I noticed,
that the lotion of nit. argent, had no influence on the ulcers in the mouth
until the condition of the stomach was corrected. In two weeks after she
recovered from the second attack; the disease again returned; mouth exceed-
ingly tender ; edges and under part of the tongue covered with ulcers ; tongue
furred; scanty, pink-red coloured urine; throws down a heavy precipitate on
standing; frequent pulse; hectic, exhausting nocturnal perspirations; loss of
appetite; pyrosis; flatulence; discharges from bowels hot and excoriating;
flow of saliva abundant; emaciated fast, and began to sink low. Aqua calcis
was given for burning at epigastrium, without producing the relief it had
done formerly, but the bicarbonate of soda was given with a very pleasant
effect. My patient at this time had not been out of bed for several weeks,
and with difficulty could turn herself in bed. At this juncture she was or-
dered cod-liver oil — a tablespoonful thrice a day in a little brandy — sub-
nitrate of bismuth five grains thrice a day ; quinine two grains thrice a day ;
solution of bicarbonate of soda as a drink ad libitum. The bismuth and soda
acted almost as a charm in correcting the state of the stomach, so that from
this treatment in four days she was much improved. The tongue and mouth
lost their fiery colour, the ulcers began to heal, the nocturnal sweats ceased,
the febrile condition of system became less, and the appetite and strength
began to return. The treatment was continued three weeks, when she was
quite restored, and continued to nurse a fine, healthy, stout boy. It required
aperients to keep the bowels soluble. The salines appeared to produce the
best influence, especially the tartrate of soda and potass; the urinary secretion
being more abundant after their use, and a consequent improvement of the
stomach and mouth. This lady fell a victim to the disease three years after-
ward. She died from ulceration of the bowels, accompanied with chronic
diarrhoea.

I might add other cases to the above, of a somewhat similar character. It
would probably extend this paper to a greater length than might be desirable.
In the foregoing pages I have tried to faithfully record my experience in this*
perplexing affection, together with the train of thought that the nature and
pathology of the disease had suggested to my mind. The following are the
authors that I have consulted on this disease, viz: "Wood's Practice; the
Lectures of Stokes and Bell; Byford, in the American Journal of the Medi-
cal Sciences; Hubbard, in do.; Shields, in Western Journal of Medicine and
Surgery; Evans and Brainard, North Western Medical and Surgical Journal;
and my former essays in North Western Medical and Surgical Journal and
Western Lancet.

1857.]

387

REVIEWS.

Art. XII. — The Treatment of Vaginal Fistula.

1. On the Treatment of Vesico -Vaginal Fistula. By J. Marion Sims, M. D ,
of Montgomery, Ala. (With twenty-two wood-cuts), pp. 24. From the
American Journal of the Medical Sciences for Jan. 1852.

2. Remarks on Vesico - Vaginal Fistule, with an account of Seven Successful
Operations. By N. Bozeman, M. D., of Montgomery, Ala. (With wood-
cuts), pp. 29. From the Louisville Review for May, 1856.

3. Urethro -Vaginal and Vesico -Vaginal Fistules — Remarks upon their Pecu-
liarities and Complications, &c. &c. By the same author. (With seven-
teen wood-cuts), pp. 23. From the North American Medico- Chiriu-gical
Review for July, 1857.

4. The History and Treatment of Vesico -Vaginal Fistula; a Report read
before the Medical Society of the State of Georgia. By P. M. Kollock,
M. D., Professor of Obstetrics in the Savannah Medical College. (With
nine wood-cuts), pp. 32. Augusta, 1857.

None can have failed to notice the remarkable advance made of late by
Obstetric Surgery. Within the century this department, aside from midwifery
proper, itself then thought almost beneath contempt, was utterly Unacknow-
ledged by the profession. Nov/, on the contrary — though the legitimacy of
its every operation, its every means of diagnosis, instrumental or manipula-
tive, and of treatment, ligature, knife, suture, escharotic, compress, injection,
are warmly — at times bitterly — contested — -it has taken its place as an inde-
pendent branch, distinct from General Surgery.

In this matter, as in others, general practitioners have been slow to acknow-
ledge the claims of those who, by ill health, abundant worldly means, or
ambition, have been enabled or compelled to devote themselves especially to
it ; although to such subdivision of labour (like that obtaining among lawyers
and naturalists), as adopted and practised by physicians of honour, good edu-
cation, and general experience, all our large communities are fast and willingly
and advantageously tending. Impartial conservatism however, nor unfair
opposition can longer withhold from obstetric surgery, unconfounded and un-
united with midwifery, its honours as both science and art. Of all the
triumphs, early and late, of this department, none excel, as few indeed of
general surgery can equal, that which we are now briefly to discuss.

The rational, or at least the successful treatment of vesical fistulas in women,
dates back hardly ten years — up to which period many, probably most cases
were pronounced, even by the best surgeons, incurable; cures where luck
gave them, being gotten only by often repeated trial; while now " the sur-
geon can approach them with a confidence of success before unknown."
We need not wonder that with the first approximation to this result was laid
at once the foundation of an individual's world-wide fame, and of the Wo-
man's Hospital of New York; well is it when, with so much public benefit,
there is found a private one at all corresponding.

sss

Reviews.

[Oct.

That these improvements are not overrated might easily be shown by
quoting opinions most authoritative at their time : —

" If the opening is large, close it with a double stitch (the edges of the
wound having been refreshed), keeping the flexible catheter in the bladder
until it is entirely filled up. I wish this operation may not be found imprac-
ticable/'1 (Smellie, 1766.)

Mr. Liston (1828) publicly said : —

" It was seldom that union took place. All, indeed, might appear to go on
well for eight or ten days ; but at the expiration of that time the wound proba-
bly would be found to have been enlarged by having been interfered with, and
would become larger and larger every time the attempt at cure was made."2
" "When the communication is to a large extent, but little hope remains to the
patient."

" In the majority of cases I fear we shall find but little benefit." " Indeed,
vesico-vaginal fistula has long been considered as one of the opprobria of sur-
gery, and, with some exceptions of late years, the cure has been giveu up as
hopeless."3 (Churchill, 1844.)

Of such assertions, many more could be given; but there is no need.
They prove that the lesion was thought till of late almost absolutely and ne-
cessarily incurable. Even at the present day, professed and standard surgical
text-books may be found, which pass over this " most distressing and intolera-
ble accident to which females are subject" in silence.

Urinary fistulas in the female, whether affecting the urethra or bladder,
whether involving the vagina merely or the cervix uteri, and whether single
or not, have presented to treatment an almost endless succession of obstacles,
among which the difficulties of preliminary exploration and of operation were
not alone ; in the hands of the best surgeons and nurses, ligatures would cut
and slough away, or urine would come dribbliDg through between them.

We shall follow these obstacles one by one, seeing how they have been
successively met and overcome, rather than take up chronologically the va-
rious operations that have been proposed.

Preliminary Exploration. — It might be supposed that to ascertain the ex-
istence of a vesical fistula, is a matter very readily accomplished ; this is not,
however, the case. Far less is it easy, in many instances, to diagnose the size,
position, and exact relations of the aperture in question, even when its exist-
ence is beyond all doubt. Y/e were once called upon to operate for fistula,
diagnosed as such by one of the first obstetricians now living in this country.
On examination, the vagina was found large, unbridled, presenting none of the
difficulties shortly to be considered, yet there was no fistula. The case was
one of chronic and intermittent incontinence of urine, of many months' stand-
ing, undoubtedly identical in origin with the temporary form not uncommon
immediately after delivery. Such a mistake might readily be made on casual
or imperfect examination. In a vagina large, wrinkled, flabby, reekiDg with
ieucorrhea, and perhaps heated by chronic vaginitis, a stream of urine trick-
ling upon the finger from a relaxed meatus might well give the idea of an
abnormal passage, especially if that idea had already been entertained from
the patient's description.

But it is as regards the character of an existing orifice, that most diffi-
culties have been found. There are frequently contractions of the vagina,
cicatrices, bands, which must be dilated or divided, their interstices and

1 Midwifery, vol. i. p. 386.

2 Lancet, June 23, 1828.

3 Diseases incident to Pregnancy and Childbed.

1857.] Sims, Bozeman, and Kollock, Treatment of Vaginal Fistula. 389

angles giving passage to the urine, and to the touch all the characters of the
fistula itself save one — a distinguishable transit through the vesical wall. Nor
are these preliminary divisions always so easy as might be imagined. Fre-
quently necessary very high up, and through a tissue tense and resisting, yet
not perfectly to be governed under the knife, they offer all the dangers at-
tending incision of the cervix for dysmenorrhea or sterility, whether of peri-
tonitis or pelvic abscess, and are not always so readily performed.

The position of the patient, seemingly so trifling a matter, is of the first
importance. Originally it was thought best to put the patient on her back,
as for lithotomy, the position recommended by Jobert, Kennedy, Hayward,
Malgaigne, and almost every operator save Velpeau and Chelius, till Sims, in
1852, drew attention to its inconveniences. This surgeon, in advocating the
change to the knees, has evidently fallen into an error concerning priority of
the proposal. He claims that while he had chanced upon this plan in 1845,
previous to the translation of either Velpeau or Chelius, its advantages had
been perceived or made public by no other save themselves till after 1852.
On the contrary, as early as 1840, Dr. Churchill, of Dublin, uses the follow-
ing language : —

"I have found the knees and elbows far more convenient, and I think less
offensive to the patient's feelings. The light can reach the part more readily,
and the position of the operator is more convenient."1

Sims places his patients on an ordinary table, which is not found to answer
every indication when an anaesthetic has been administered. Kollock has
constructed a special table, with a movable stage — convenient, doubtless, in an
operating theatre, but not easily carried from house to house. We have pre-
ferred in practice the following plan, suggested in all its details by a colleague,
Dr. Nathan Hayward, of Roxbury. Nothing can be simpler, nothing more
convenient. A common high-backed chair, or a small old-fashioned wash-
stand, properly guarded by pillows, is placed on its face upon the bed ; over
its back the patient is made to bend, her arms extended and secured, her
knees at a right angle strapped to the rounds or sides of the frame. She is
thus immovably confined in just the posture needed, and the attendance of
one or two additional assistants rendered unnecessary. To simplify the matter
still more, the anaesthetic may be permanently placed under the patient's face
on a cricket, or suspended there from the cross-bars of the frame, or, as in
our actual practice, her nightcap may receive the sponge, and then be tied
over her face.

Before operation, the fistula must have been brought into view, and room
made for all necessary manipulation. Good light is necessary, best that of
the sun, direct if possible, or reflected from a mirror as suggested by Sims.
A careful exploratory examination must, of course, have been made, the size
and position of the fistula have been accurately ascertained by engaging therein,
and thus offering to the touch per vaginam, the point of a sound, or catheter,
or bougie, or probe passed into the bladder by the urethra. All bridles and
adhesions of the vaginal walls must have been divided by previous operation ; and
what none seem to have proposed or thought of, the vagina should have been
dilated, unless already far more patulous than usual, to its utmost limits by
huge sponge-tents — well shaped and properly placed, these will not increase
the size of the fistula. The importance of another preliminary seems also to
have escaped notice; by confining the patient to bed for a few days previously,
as found so useful before many capital operations, and by putting her on full

Diseases of Pregnancy and Childbed.

390

Reviews.

[Oct.

preparatory doses of ox-gall during this period, as insisted on so strongly by
Clay, of Manchester, before ovariotomy, the tendency to subsequent unpleas-
ant symptoms is greatly diminished. And finally, in those frequent cases
where the urine inclines to profuse calcarious deposit, which might tend
mechanically to irritate the wound, and thus, both directly and indirectly, to
prevent its closure, it would be well to enforce the plan lately proposed by
Kollock, and exhibit sulphuric acid internally for some days previous to the
operation.

Next in importance, as in natural sequence, to the position of the patient
and the access of light, is found the temporary dilatation of the vagina or re-
pression of its walls; without thoroughly securing which, the operation can
hardly be performed. A variety of modes of effecting this have been pro-
posed; specula of various kinds, tubular, double-bladed, or resembling that
for the rectum, as suggested by Montgomery; all of them affording so con-
tracted a space for manipulation as to render it tedious, difficult, or impossible.
Bent spatulae, more or less in number, have been used, requiring the presence
of several assistants.

The only instrument as yet suggested which at all answers the indication, is
the admirable duck-bill speculum of Sims, as made by Otto and Kcehler, of New
York, which by elevating and supporting the perineum, the patient being in
proper position, thus opens the vagina to an enormous extent.

The Operation. — Cauterization of the fistula has had many advocates, both
as a distinct and sufficient operation by itself, and for merely preceding suture,
in place of the knife, for which last indication it cannot be too summarily
condemned.

As an absolutely curative method in vesical fistulse, the cautery has been
greatly overrated. Hardly a case can be instanced where it has been perfectly
successful. The fistula can easily be reduced in size by it, but seldom entirely
obliterated, whether there be used Dupuytren's acid nitrate of mercury, the
nitrate of silver, or the hot iron. Some experience of the two latter, and in
Edinburgh of the electro-galvanic wire, as advised by Marshall and Middel-
dorpf, has been to us far from satisfactory.

The operations by suture have been many and diversified, all of them suc-
cessively lauded, but most of them till of late have failed. Here, as in so-
many other operations, the simplest means have ultimately proved the best.

Each step in the process has given opportunity to surgeons for an endless
succession of methods and complications. To depress the fistula, to refresh
its edges, to replace protrusions of the vesical mucous membrane, the needle,
to pass it, the ligature, to secure it, all have been battle grounds. The methods
and instruments of Hobart, of Malagodi and Beaumont, of Schreger, Fabbri
and Ehrmann, of Laugier, Lewzinsky and Colombat, of Roux, Deyber, Chas-
saigne, Desault and JDupuytren, down to the late ones of Mathieu and Baker
Brown, bear witness only to the baffled ingenuity of those who proposed them.
The serrefines brought forward last year by Bertet,1 though so much more
simple, prove as useless as the intricate leaf-clamps of Naegele and Lallemand.

Nor need more be said of the plan of Vidal de Cassis, for permanent
closure of the vagina, an operation even now, perhaps, necessary in some cases
where the cervix is involved, but in all others superseded and unjustifiable ;
nor for the same re? son, of the plastic dissections of Jobert, Leroy d'Etiolles,
and Velpeau, save to claim for the assertions of the former, which have gained
for him such extensive reputation, their fair share of incredulity.

1 Union Medicale, Aug., 1856, p. 375.

1857.] Sims, Bozeman, and Kollock, Treatment of Vaginal Fistula. 391

It is somewhat remarkable that most of the really important advances in
the treatment of vesical fistulas have been made in this country. Previous
to the suggestions just alluded to, whose authors curiously enough were resi-
dents of the same place (Montgomery, Alabama), Pancoast, of Philadelphia,
had secured union by dovetailing the raw edges of the fistula together; Hay-
ward, of Boston, by so dissecting as to supersede the necessity of involving
the mucous membrane of the bladder in the stitch, had insured a broad sur-
face of adhesion and avoided a principal danger ; and Mettauer, of Virginia,
had substituted for other sutures, and secured them by twisting, threads of
lead. To each of these gentlemen great credit is due for their several parts
towards the simple and effectual operation now attained.

In January, 1852, there appeared in this Journal that proposal by Dr.
Sims, now of New York, which for successful result will remain as it has been
the greatest triumph of obstetric surgery. This operation, conceived in
1849, naturally succeeds those of Hayward and Mettauer, and in reality is
based on a judicious combination of the essential points of those two methods.
It consists of Hayward's stitch, down to but not perforating the mucous
membrane of the bladder, made with Mettauer' s metal thread, secured not
by the twist, difficult of perfect adaptation and liable to become loose, but by
immovable clamps to metal quills.

Perfect adaptation of the parts in most cases was thus secured, firm lateral
pressure over a wide surface with less danger of laceration, and by a material
unirritating and of itself offering but slight obstacles to an immediate union.
It seemed probable that all had been accomplished that could be possible, if
not all that might be desired, and we need not wonder at the prophecy of
Mott concerning his friend, that " in all coming time he would have an endur-
ing monument of his talent, his genius, and his philanthropy, in the gratitude
of woman."

"For," as said Dr. Francis, of New York, "prior to the discovery, surgery
could do nothing for this formidable class of affections. In Germany, Dieffen-
bach, Jaeger, Wutzer, and others, had exhausted all their resources in vain.
Prolific Germany seems in this instance to have been barren. In France, De-
sault, Dupuvtren, Lallemand, and more recently Jobert, Vidal, and their con-
temporaries, had been equally unsuccessful, although Jobert claims a success
that has never been demonstrated, and I fear that this eminent man, like the
late Lisfranc, had scarcely that devotion to practical results, which the written
annals of medical science demand from all who give publicity to their cogita-
tions and the issues of their practice. In England, their greatest men, their
Coopers, their Abernethys, their Lawrences, their Guthries, could do nothing.
Nor have I learned that there has emanated from that practical school of medi-
cal and surgical learning which sheds so much glory over Ireland, a single
practical idea that can be truly said to have favoured this improvement; and
Scotland, while she justly boasts of her Simpson, has yet to be enlightened by
that great professor, ere she can add successful results of practice in these
cases, to her ample list of chirurgical and obstetrical improvements. In Russia,
which proffers claim to our regard for substantial and effective light on several
of the obscurest subjects of the healing art, we can testify to no advancement
in a knowledge of the intricacies involved in this department of female in-
firmity. Thus we find universally abroad, nothing but a lame and impotent
conclusion to this order of experiments."1

There were difficulties, however, attending this operation, which Sims in part
foresaw, and with an honourable candor acknowledged to exist. He says : —

" The clamps, burrowing in the vaginal surface, leave a deep sulcus on each
1 Addresses, &c, at opening of Woman's Hospital, New York, 1856.

392

Reviews.

[Oct.

side of the new cicatrix, which, when they are removed too soon, fill up by
granulation. It is a law of all granulating wounds to contract as they heal,
and this contraction on each side of the new cicatrix is often sufficient to pull
it gradually apart. Accidents of this sort have happened repeatedly in my
hands, from a too early removal of the suture apparatus. Great judgment,
which experience alone can give, is necessary to determine the length of time
that the sutures ought to remain intact, for no positive rules can be laid down
that will answer invariably in every case. I have also seen serious mischief
result from leaving the clamps too long imbedded in the parts. Their burrowing
and ulceration may extend entirely through the vagino- vesical structure, thereby
substituting newfistulous openings for the original one. This complication is by
no means incurable, but only prolongs the treatment and postpones ultimate suc-
cess. In two or three instances I have witnessed a still more serious accident
from an undue pressure of the clamps, viz., a strangulation of the inclosed
fistulous edges, which unfortunately resulted in a sloughing of the tumefied
parts, and a consequent enlarging of the opening."1

The experience of the profession for now five years has added to these acci-
dents, others —

" The wires will cut themselves out in certain cases, however much attention
may be bestowed on their introduction at a sufficient distance from the edge of
the raw surface, and sufficient depth into the submucous tissue; the lips in-
cluded between the clamps will slough, however much judgment may be exer-
cised in drawing them together, and irregularities on the vaginal surface,
rigidity from cicatrices, and the situation of either a part or whole of the fistu-
lous opening, may prevent the clamps from being evenly applied, and with
sufficient parallelism to secure their regular and efficient action. In conse-
quence of these occurrences the patient has to be subjected to a greater or less
number of repetitions of the operation; and, perhaps, other means hare to be
employed for the perfection of the cure."2

Collis, of Dublin, and Spencer Wells, of London, have endeavoured to
overcome these disadvantages by methods published during the past winter.

The first consists of Sims' operation with this modification, that both edges
of the fistula are deeply split, these fissures separated and secured by India
rubber quills, face to face.3 The second substituted a pin, armed with shot
and perforated bars, for the silver wire.4 These plans, however, had been
anticipated by one infinitely better.

It is to Dr. Bozeman, of Alabama, to whom it accidentally .suggested itself,
that we are indebted for the long looked for discovery, now known as the
button suture. His first paper was published in the spring of 1856, and he
has lately made known the results of a more extended experience, by diagrams,
accurate descriptions, an elaborate classification of all possible varieties of fis-
tula, and directions for perfectly adapting his apparatus to each and every
one of them.

The early stages of his operation are identical with those already described.
Silver ligatures are used, but are introduced directly and without the aid of
any other thread. Instead of being fastened to metal quills, the extremities of
the wires, brought together like Mettauer's before twisting, are passed through
minute perforations in a shield of lead, which is found to answer much better
than the silver at first proposed, and, as by Sims, clamped securely with shot.

It is claimed that the metal shield will — better than Sims' cross-bars —

1 This Journal, January, 1852, p. 70.

2 Kollock, work under review, p. 17.

s Dublin Quarterly Journal, Feb., 1857, p. 122.
4 Med. Times and Gazette, Feb., 1857, p. 141.

1857.] Sims, Bozeman, and Kollock, Treatment of Vaginal Fistula. 393

1. Act the part of a splint in keeping the approximated edges in close con-
tact, and at rest;

2. Prevent the wires from cutting out; and

3. Protect the edges of the wound against irritation by the urine, vaginal
discharges, or atmosphere.

The button suture has now been fairly tried. Successful cases have been
reported, besides the fifteen or more of Bozeman, in this country, by Gaston,
T. Wood, Kollock, Williams, and others ; and in Great Britain, by Spencer
Wells and Baker Brown ; all of whom corroborate its excellence. Kollock' s
report, indeed, prepared evidently with care and well and candidly written,
is mainly occupied by cases from his own practice, showing the relative merits
of the clamp and button.

Dr. Bozeman has found that the more difficult cases of ordinary fistula can
be easily cured, but there are two lesions he has mastered which have hitherto
been entirely beyond surgical aid.

The first of these is a longitudinal laceration of the edge of the meatus,
" the most unfavourable form of all the urethral injuries," for which no treat-
ment had ever even been proposed.

The other victory alluded to is in those cases where the cervix uteri is
directly involved in the fistula. Nothing had here been done unless by Vidal's
method of closing the vagina, save by Jobert; who, until lately, by extensively
dissecting away the attachments of the cervix, whether or not accompanying
this by the insertion of a flap from a distant part, managed to close the fistula,
but lost his patients by peritonitis.

Bozeman, on the other hand, claims better fortune. By his method the
uterus itself is dragged down, the edges of the cervix are pared, just as with
any part of the vesico-vaginal septum, and stitches inserted into its sub-
stance.

The idea of this bold procedure, as novel as it is successful, had undoubt-
edly presented itself in part to the mind of Velpeau,1 who speaks of the pos-
sibility of dragging down the cervix and making it subservient to closing the
fistula, but remarks : " All these suggestions want a foundation to rest upon;
none of them can yet adduce any success in their favour ;" and Jobert, im-
proving upon himself, relates at the close of the last year a case in which
sutures were passed through the cervix;2 but the credit of having independ-
ently conceived the operation in all its completeness, and of having put it
into actual practice, is undoubtedly Bozeman's.

The results obtained add only another to the many proofs that the cervix,
and, indeed, uterus itself, can bear immensely more manipulation with impu-
nity than is generally supposed.

After- Treatment. — The operation being completed, the great essentials for
its success are perfect rest of body (best upon one side) and of mind, a com-
plete stagnation obtainable by opium, of one class of excretions, the intestinal,
and a perfectly unimpeded passage of those from the bladder.

In all cases, almost without exception, Sims' catheter, self-retaining by its
double curve, is invaluable. When fitting well, of course an essential, it is
found to answer every indication. In those obstinate lacerations of the meatus
already referred to, this instrument cannot be borne; but, by an ingenious
arrangement of his button shield, Bozeman has compelled it, though designed
for an entirely different purpose, successfully to take the place by affording
the necessary support to a male elastic.

1 Operative Surgery, vol. i. p. 627.

2 Union Medicale, Nov., 1856.

394

Reviews.

[Oct.

The button suture is still in its infancy. It will, undoubtedly, be found
useful for other lesions than vesical fistula. We have, indeed, used it already
for such, and shall elsewhere report a successful case.

The preceding remarks will have given some idea of " the difficulties/' to
use Sims' words of his own early experience, " that had to be overcome, the
many disappointments that had to be borne before ultimate success; which, as
it will be seen, was the work not of a day, and the result not of accident, but
of long, laborious, and persevering application."

Almost every variety of vesical fistula in the female seems now to have
been brought within the reach and control of art except those invading the
cavity of the uterus, and the unique form reported by Simpson as a sequence
to pelvic abscess, a fistula between the bladder and rectum without in the
least implicating either uterine or vaginal canal.1 The first class of these
cases may yet possibly be made curable after free dilatation of the cervix uteri
by carefully placed sponge-tents ; but the latter, it would seem, must ever
remain beyond hope.

Of other vaginal fistulas, also the results, most of them, of pelvic abscess,
and unconnected in any way with urethra or bladder, we can here say nothing.
They form in their relations and treatment a most interesting group among
the diseases of women, but their history has yet to be written.

H. R. S.

Art. XIII. — Adulterations Detected; or Plain Instructions given for the Dis-
covery of Frauds in Food and Medicine. By Arthur Hill Hassall,
M. D. London, 1857.

On the Composition of Food, and how it is Adulterated ; with Practical Di-
rections for its Analysis. By W. Marcet, M.D., F. C. S. London, 1856.

The subject of the adulteration of drugs was first brought before the notice
of the American Medical Association at at its annual meeting at Baltimore in
1848. A communication was then read by Dr. T. 0. Edwards, at that time
member of Congress from Ohio, in which an exposure was made of the great
prevalence of adulteration in imported drags, and of the evils necessarily re-
sulting from it. The Association at that time presented to Congress a memorial
on the subject, recommending prompt legislation; and a bill was accordingly
passed, the same year, providing for the appointment of drug inspectors in all
the principal ports of entry, whose duty it should be to examine critically all
medicinal articles imported into the country, and refuse admission to such as
were adulterated or in any way deficient in quality. These inspectorships have
been continued from that time to the present.

The exposures which were made, at the period referred to, of the worthless
character of many imported drugs, attracted immediately the attention of the
profession, and will no doubt be fresh in the minds of many of our readers.
The discovery that they had been for some years employing in practice opium
from which the morphia had been wholly or in part extracted, or scammony
which consisted of scammony, flour, gamboge, and chalk, equal parts, was natu-
rally calculated to excite a lively interest in the minds of practical physicians.
It was very evident that some check to this wholesale and injurious adulteration

1 Edinburgh Monthly Journ. of Med. Sciences, Dec, 1852 ; Obstetric works.

1857.] Hassall and Marcet, Adulterations in Food and Medicine. 395

was absolutely necessary; and the appointment of the government inspectors,
mentioned above, offered the most direct and efficient means of arresting the
evil.

It appears that this measure has been productive of considerable benefit.
Six months after the law went into operation, Dr. Edwards made a report to
the Secretary of the Treasury, in which he designated the following as the
beneficial effects which had resulted from its operation : —

1. An elevation in the quality and purity of the medicinal agents imported.

2. An entire prevention of adulterated and deteriorated drugs from entry
and use.

3. No embarrassment to the honest importer and dealer.

4. An increased revenue.

5. Protection to the medical profession and community, an increasing con-
fidence, and an earnest desire on the part of the people for the continuance of
the law and its faithful application.

The effect of the law was soon felt, it was said, by the European' exporters,
so that they ceased to send worthless medicinal articles to this country, as
formerly; and consequently a much smaller proportion of the imported drugs
were condemned during the second than during the first year after the esta-
blishment of the law. Indeed, a committee of the Association were informed
by Dr. Bailey, drug inspector for the port of New York, in 1849, that not
one-tenth of the spurious and adulterated articles arrived at that time that
there did before the passage of the law. The uneasiness of the profession,
which had been excited by the unpleasant discovery of the extensive existence
of adulteration, was therefore somewhat quieted by the assurance that the evil
was effectually arrested, or at least in a fair way to become so.

At the same time, however, a certain degree of suspicion remained behind,
that the remedy which had been adopted was not, after all, completely effectual.
Dr. Edwards was very possibly right when he claimed, as one consequence of
the operation of the law, an entire prevention of adulterated and deteriorated
drugs from entry; but it is by no means certain that it would as effectually
prevent their use. If the foreign dealer and manufacturer found it a profit-
able business to adulterate drugs before importation, there is no reason why
our own should not find it equally profitable to adulterate them afterward.
The foreign adept in this kind of manufacture need not even allow the busi-
ness to be taken out of his hands. It would only be requisite for him to
establish a "New York Branch" of the original London or Brussels establish-
ment, and he might then continue his operations with the same facility as
before. These considerations, accordingly, still weighed with the minds of
some of the profession, and prevented their being entirely satisfied with the
establishment of the drug inspectorships.

The American Medical Association, furthermore, at their meeting in 1848,
appointed a committee of five to report at the next meeting — first, the nature
and extent of the sophistication and adulteration of drugs, as practised by the
wholesale dealers and retail druggists;- and, second, the best means for the pre-
vention of the evil in its various forms.

Such a report was accordingly made in 1849. The committee state that
they have made inquiries of wholesale and retail dealers respecting home
frauds, "without obtaining much exact information," the dealers being found
"unwilling," from some cause or other, "to give any statements except of a
general character;" exciting, in this way, a natural suspicion that home adul-
terations had already, to a certain extent, taken the place of the foreign. The
committee appear to have ascertained, however, the existence of adulteration

396

Reviews.

[Oct,

in many articles of domestic preparation, as well as in some of foreign manu-
facture which had passed the custom-house in a pure state ; and they come
finally to the conclusion that u there are enough" in our country "ready to
engage in such dishonest work on a large scale, and so great is the tempta-
tion, now that foreign adulterations are excluded from our ports of entry, and
the prices of medicines consequently enhanced, that it will require the utmost
vigilance of this Association and of the public to prevent their carrying it on."

Notwithstanding this, the committee for 1850, to whom the continued con-
sideration of the subject was intrusted, reported, in general terms, that do-
mestic adulteration seemed at that time not to have increased, but even rather
to have diminished; and that adulterated medicines were "not commonly
vended in our large cities" (unless by those engaged in the sale of nostrums),
except under certain particular circumstances. What these particular circum-
stances were, did not very clearly appear from the report of the committee.
In fact, the special instances mentioned in the report showed so much impurity
in the drugs actually in the market, as rather to contradict the conclusions
just cited ) as, for instance, where samples of rhubarb and cinchona, obtained
in Boston, were respectively only one-half and one-eighth the proper strength;
and where, of fifteen samples of blue mass, obtained in St. Louis, only one-
third gave an approximation to the officinal proportion of mercury. Cod-liver
oil, again, was found to be so extensively adulterated that " hardly a tenth,"
it was believed, of what was sold under that name was genuine, being either
refined whale or sea-elephant oil. It seems rather difficult to reconcile such
facts as these with the belief that adulterated medicines were "'not commonly
vended in our large cities."

Still, the report of this committee was, in its general conclusions, rather
calculated to quiet the agitation of the subject of adulteration, and to convey
the idea that it was, on the whole, not a very gross evil, at least in the Atlantic
cities. The committee suggested as remedial measures the following : —

1. That the various State and local medical societies be requested to annu-
ally appoint boards of examiners, whose duty it shall be to procure specimens
of drugs from the stores within their limits, for examination, and report upon
the same to their respective societies at least once in every year.

2. That the respectable druggists and apothecaries throughout the United
States be requested to take active measures for suppressing the fabrication and
sale of inferior and adulterated drugs ; and that it be respectfully suggested
to them, wherever practicable, to form themselves into societies or colleges for
the promotion of pharmaceutical knowledge and general improvement in their
profession.

3. That a committee be appointed, consisting of one member from each
State here represented, whose duty it shall be to collect information in regard
to spurious and adulterated drugs, and report the same at the next meeting of
the Association.

These suggestions were adopted by the Association, and a committee ap-
pointed accordingly ; but nothing has since been done, so far as we know, in
regard to the matter. Practically, the whole work of protecting the community
against the use of adulterated medicines has been left, since 1850, to the cus-
tom-house inspectors appointed by the law of 1818.

Now, we believe that the almos* universal verdict of medical men, even in
the large Atlantic cities, at the present time, will be that this law has been
•practically ineffectual in preventing the extensive sale and employment of spu-
rious and adulterated drugs. The complaints of constant disappointment in
the operation of simple and important drugs, which ought to be reliable, and

1857.] Hassall and Marcet, Adulterations in Food and Medicine. 397

of their extremely variable efficacy, were never more frequent than at the pre-
sent moment. There can be little doubt that the general skepticism as to the
efficacy of therapeutical agents, now so prevalent among physicians, and which
has been almost constantly on the increase, is at least partly owing to the de-
teriorated quality of the drugs themselves. The inefficiency of the custom-
house examination depends probably upon two causes. First, the inspectorships
are liable, we regret to say, like almost all other government offices in our
country, to be regarded as purely political appointments, and to be conferred
on purely political grounds, with but little if any regard to the professional
qualifications of the appointees. It is to be feared that this mode of conferring
appointments has become so interwoven with our political system as to leave
but little prospect of its modification for the b.etter, and little security for the
capacity, or even the integrity, of the inspectors. Even if this were not the
case, however, and if we could be assured that none but genuine drugs were
ever allowed to enter our ports, there would still remain a second and much
greater difficulty, and one entirely beyond the reach of any custom-house su-
pervision: that is, that drugs, as we have already intimated, are just as liable
to be adulterated after as before importation. The same inducements for it are
held out to the. unprincipled dealer and manufacturer, and the same injurious
results to the community follow from its practice.

Dr. Hassall, whose book on the adulteration of food and medicine has more
recently called attention to this subject, indicates the only effectual mode of
detecting these impositions. Adulterations must be detected in the samples
sold or kept for sale by the retail dealer. All other inspections, whether of
the crude imported or domestic material, or of the recently manufactured or
wholesale article, though useful to a certain extent, must necessarily be incom-
plete ; since adulteration may be, and certainly is, practised, according to the
observations of Dr. H., at any point between the custom-house and the counter
of the retail druggist. In England an excise law exists, similar in its opera-
' tion to the inspectorships of the United States; and yet the amount of adul-
teration practiced in the former country, in articles of both food and medicine,
is so extensive and scandalous as to excite the indignation of any one who will
take the trouble to read over the details which this book presents. Scammony
made up of "guaiacum and jalap, with woody fibre, cellular tissue, and other
insoluble matter;" powdered jalap, consisting, for one-third of its bulk, of rasped
wood; ipecac, containing "large quantities of carbonate of lime or chalk;"
quinine, containing gum, starch, chalk, stearine, carbonate of magnesia, &c.
&c. ; such are the drugs which are actually in the English market, and in daily
use by practising physicians in that country.

Now it is a very essential question for us whether we are any better off, in
this respect, than the English. We seem to have settled down, since 1850,
into a somewhat quiescent state about this matter, trusting to the existing
laws for protection. It has already been shown that these laws do not and
cannot protect us. Supposing the custom-house requirements to be thoroughly
and fairly carried out, the nine years which have elapsed since 1848 have
certainly afforded time enough for a tolerably active and quick-witted people
to learn all the tricks that were formerly done by foreigners, and to gain suf-
ficient experience for successfully practising them at home. Some further
precautions, therefore, must be adopted, unless we are willing to continue in
the use of such medicines as are to be found in the market at present. A
few reflections, suggested for the most part by Dr. HassaH's book, will show
that the subject is fully deserving of all the consideration we may bestow
upon it.

398

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[Oct.

Adulteration consists in mixing with the genuine article other substances
of inferior value, which increase its bulk and enhance accordingly the profits
of the vendor. The foreign substances which are selected for this purpose
are usually such as may be readily incorporated with the original article, so
as not to be easily detected by ocular inspection. They are, in many cases,
simply negative in their properties; and so far, the effect of the adulteration
is merely to diminish the efficacy of the medicine; as, for example, where
opium is adulterated with clay, or alcohol with water. This adulteration
may be carried to such an extent that the properties of the original article
are, for all practical purposes, entirely destroyed; and it then amounts to a
complete substitution of other materials for those of which it should properly
be composed. Hassall states, for instance, that samples are occasionally to
be met with, professing to be scammony, which " do not contain a particle of
that drug, or small proportions only/' and are made up of a variety of ingre-
dients, including even wood and ivory-black.

In most cases, however, the simple adulteration of a drug with an indif-
ferent substance, or its dilution, as it might be called, is not the only or the
most important alteration which it is made to suffer. The admixture of large
quantities of foreign material necessarily impairs the sensible properties of
the drug; and these must be restored or imitated as well as possible, by a
further adulteration. Thus Cayenne, according to Dr. Hassall, is extensively
adulterated with ground rice, and its colour afterward restored by the addition
of red lead, or even the red sulphuret of mercury. Mustard is adulterated
first with wheat flour or clay to increase its bulk, then with red pepper to
give pungency to the mixture, and lastly with turmeric or chromate of lead to
restore its colour. The purchaser is, therefore, not only defrauded of the
article which he wishes to procure, but is supplied at the same time with
other materials which are absolutely injurious.

It would seem almost superfluous to point out the injurious effects of such
practices, and their disreputable character; and yet there is a tendency in the
minds of some, resulting principally from a too hasty consideration of the
subject, to overlook some kinds of adulteration as unimportant, or to palliate
them as excusable. This has sometimes led to a distinction between inju-
rious and harmless adulterations; the former class including those cases in
which deleterious substances, such as red lead or arsenite of copper are fraud-
ulently introduced into the mixture ; the latter including those in which the
bulk of the article is simply increased with some indifferent substance, as
where milk is adulterated with water, or calomel with chalk. The slightest
consideration will show, however, that all adulterations, especially in medi-
cinal articles, are injurious and dangerous, as well as fraudulent. If we pre-
scribe six grains of calomel to a patient who requires the operation of the
drug, and three grains of the powder which he takes under that name con-
sist of chalk, it is not merely a pecuniary loss which he suffers, but an actual
bodily injury. Even should the adulteration be detected the next day, its
effects cannot be counteracted by giving another similar dose of pure calomel;
for the time for the most favourable operation of the drug has passed, and
the patient's illness is, at the very least, prolonged for twenty-four hours. It
is easy to see that much more striking cases than this, and cases quite as
likely to happen, might readily be cited. But it is not necessary. There is
plainly no proper distinction, except in degree, as to the danger of adultera-
tions in medicine. They are all injurious; and those which are ordinarily
the least so, may at any time become extremely dangerous, owing to the acci-
dental circumstances of the case.

1857.] Hassall and Marcet, Adulterations in Food and Medicine. 399

But there is another excuse which we frequently hear from those engaged
in the trade, and which is too often allowed to pass current, to a certain ex-
tent, even among professional men. It is the following: There are, it is said,
in all articles of merchandise, different grades of quality, corresponding to
the means and taste of the purchasers. Articles of the first quality, which
necessarily bear a high price, are within the reach only of the wealthy ; infe-
rior goods, at a cheaper rate must be supplied to the poorer classes, for they
would otherwise be obliged to go without altogether. Accordingly, there are
always to be found in the market goods of these different qualities with cor-
responding prices. It must necessarily be so; and in the drug trade as well
as in others. There is no fraud in this, it is said. On the contrary, it is
perfectly well understood that the higher priced articles are always the best,
and the cheaper of an inferior quality. If the customer is willing to pay for
the best article, he can have it. If he prefers to purchase at a cheap rate, he
can be accommodated with an article, corresponding in quality and in price.

Now, it will be observed that the above excuse or explanation, plausible as
it seems, rests entirely for its justification on the presumption that the vary-
ing quality of the article, corresponding with its price, is perfectly well known
to all parties, purchaser as well as dealer. So long as this is the case, the
variation in quality is certainly not a fraud upon the public, but rather an
accommodation. When a man buys a fine broadcloth coat for thirty dollars
and a rough peajacket for five, he understands perfectly well the reason for
this difference in price. It is evident on mere inspection of the articles; and
so long as the articles are good of their kind, and actually are what they pro-
fess to be, no harm is done, and the transaction is strictly honourable.

But the case is very different when the inferior article is fraudulently made
to resemble the better one, and sold as actually being such. There is a cer-
tain class of dealers in clothing, who make a business of getting up, in this
way, garments of sham quality ; smooth and lustrous externally, but put
together of such inferior materials, and in such an inferior manner, that they
are ready to fall to pieces after a few weeks' wear. They are sold at a less
price than similar garments of the best quality, but they are sold as really
being such ; and the unsuspecting purchaser is led to believe that he is really
obtaining a good article at a lower price than he could get it for elsewhere.
This kind of trade is properly regarded everywhere as dishonest ; and those
carrying it on are not considered as belonging to the class of respectable
tradesmen.

Now, the adulteration of drugs, for the purpose of supplying a cheap and
more saleable article, is the same kind of transaction with that just described.
There is, and can be, in the nature of the case, no difference in the quality
of the real drug. Scammony is scammony, and sulphate of quinine is sul-
phate of quinine ; and always of the same composition. But when scam-
mony is mixed with guaiacum and the mixture sold as scammony, or when
sulphate of quinine is adulterated with chalk, and the mixture sold as sul-
phate of quinine, such a transaction is nothing less than the sale of one arti-
cle in place of another, and is therefore fraudulent and disreputable. It is
useless to say that the cheap article cannot be supposed to be as good as the
high-priced one, and that the fact of its adulteration is well known to the
trade. TJie consumer does not know it. The consumer buys the article, sup-
posing it to be scammony or quinine, and not a mixture of worthless or dele-
terious substances. In this fact lies the fraud. The truth is, the dealer in
adulterated medicines is not guided by any desire to accommodate the public,
but simply to enhance his own profits : for though the spurious mixture is

400

Reviews.

[Oct.

sold at a less price than the pure article, it brings a higher price in propor-
tion than it is really worth. Thus coffee is adulterated with an equal bulk
of chiccory, and the mixture sold at a price intermediate between its real
value and that of pure coffee. Opium, from which the morphine has been
extracted, is sold as a low-priced opium, when it is in reality altogether with-
out value.

The matter, therefore, becomes perfectly simple, as soon as subjected to a
moment's examination. The keeping and vending of adulterated drugs are
fraudulent, no matter what may be the mode or manner of its performance.
It is to be regretted, therefore, that in the report of the Committee on Adul-
teration, made to the American Medical Association in 1850, some expres-
sions occur, which might be regarded as palliating its practice to a certain
extent among the trade.

"Extensive inquiries among physicians, manufacturing chemists and drug-
gists," say the committee, " have led to the following conclusions : First, that
the wholesale druggists in the large cities, equally in the South and West as
in the Eastern States, who are not specially engaged in selling nostrums, either
as proprietors or agents, conduct their business on fair and honourable princi-
ples. As a general rule, they buy their choice chemicals from those who ma-
nufacture them, and either import other articles, or get them directly from
those who do ; and are always disposed to supply good articles to customers
who are willing to pay a remunerating price. At the same time, many of this
class keep inferior articles which they dispose of for a corresponding price to
physicians and storekeepers who insist on buying at reduced rates."

Now, it is difficult to reconcile this trade in "inferior," that is adulterated,
drugs with " fair and honourable principles" of business. These adulterated
drugs are purchased by the retail dealers in order to be sold as genuine. It
is not true that the public are ever parties to the transaction; or that they
prefer a cheap article, knowing it to be adulterated. No man, suffering with
intermittent fever, would buy a cheap quinine in preference to a high-priced
one, if he knew that he would be obliged to take a teaspoonful of the former
for every grain of the latter. The retail sale, which is the end and object of
all previous trade-sales, is always a fraud. The wholesale dealer knows this
perfectly well, and is, therefore, a party to the transaction, when he deals in
articles which he knows to be destined for that purpose. Keeping and sell-
ing medicinal substances, therefore, knowing them to be adulterated, under
the pretence of supplying customers who wish a cheap article, is but little, if
any, less injurious and disreputable than actually making the adulteration or
retailing the spurious drugs.

We have been led to make the foregoing remarks because it seemed to us
that the profession in this country had been lulled into a kind of false secu*
rity with regard to this subject, and to the amount of protection afforded
them by the existing laws.

Dr. HassaH's book possesses a still more general interest from the fact that
it treats extensively of the adulterations in food as well as of those in medi-
cine. Indeed, the greater part of the book is occupied by the former topic.
The author shows that in England at the present day the most important
articles of food and drink are hardly less adulterated than medicines. Some
of these adulterations are practised abroad, some of them at home; some on
foreign and some on donestic articles. In some cases the genuine and spu-
rious materials are both imported from abroad, and mixed after being brought
into the country. Dr. H.'s statements have the greater value since they are
not merely the result of general inquiries among manufacturers and dealers,

1857.] Hassall and Marcet, Adulterations in Food and Medicine. 401

but of direct examination of samples purchased at retail, and consequently in
the same condition as they are ordinarily obtained by the consumer.

An extremely important feature of the work is the extensive application of
the microscope to the detection of foreign matters in alimentary or medicinal
substances. Many adulterations have heretofore escaped detection in conse-
quence of the inability of the chemist to recognize them by any means at his
command. Some adulterations are so coarse that they may be recognized, by
any one familiar with the appearance of the genuine article, by a careful ocular
inspection ; as where foreign leaves are mixed with those of tea or senna. In
other instances, where inspection would fail, a chemical examination is suffi-
cient ', as where calomel is adulterated with substances which are not vola-
tilized by heat, or which are soluble in water. There are other cases, however,
principally those of powdered vegetable or animal substances, in which ocular
inspection and chemistry are equally at fault; as ground coffee, for instance,
adulterated with chiccory or exhausted tan, or mustard adulterated with wheat
flour and turmeric. Here, however, the microscope steps in and accomplishes
all that could be desired ; for no amount of grinding and powdering can de-
stroy the shape of the vegetable cells and fibres, or the optical characters of
starch-granules peculiar to different kinds of vegetable substances. Thus the
minute anatomical structure of all the different kinds of flour is readily recog-
nized when these are mingled together. Chiccory is detected in coffee, potato
flour in arrowroot, and the fibres of rasped wood in powdered opium. We
know of no application of the microscope, yet made, which has been more
directly and practically serviceable than this.

Tea is adulterated, according to Dr. H.'s investigations, with various foreign
leaves, such as those of the beech, elm, horsechestnut, plane, willow, poplar,
hawthorn, and sloe. Two or three kinds of foreign leaves are mixed with the
tea by the Chinese themselves, previous to exportation. The Chinese manu-
facture also a spurious article for the purpose of admixture with genuine va-
rieties, which they designate by the expressive name of " lie tea." It consists
of the dust of tea-leaves, sometimes of foreign leaves, and sand, made up by
means of starch or gum into little masses, which are afterwards painted and
colored so as to resemble either black or green gunpowder. " This article,"
says Hassall, " although the chests containing it are branded with the words
'lie tea/ was at a recent period extensively imported into this country, and of
course found purchasers."

But it is in the colouring and dressing of the real tea-leaves that the most
important, because the most extensive and deleterious, adulteration is practised.
Tea drinkers will probably be surprised to learn that with every cup of green
tea they swallow so much mineral paint, artificially put on in order to increase
the brilliancy and lustre of the leaves.

" It is with green tea/' says Dr. H., "that the practice of artificially colouring
the leaves is carried to the greatest extent. The varieties of green tea imported
into this country from China are Twankay, Hyson-skin, Young Hyson, Hyson,
Imperial, and Gunpowder. Now the colour of the whole of these teas, without
a single exception, is artificial, and caused by the adhesion to the leaves of va-
rious colouring matters.

" The usual colouring matters employed are ferrocyanide of iron or Prussian
blue, turmeric, and China clay. These are mixed in various proportions, so as
to produce different shades of blue and green; the surface of the leaves being
moistened, they are then agitated with the mixtures until they become faced or
glazed, as it is termed. Occasionally other substances are employed by the
Chinese, as indigo and sulphate of lime, or gypsum. In proof that it has long
been the practice frequently to colour green tea artificially, we have the evi-
No. LXVIIL— Oct. 1857. '11

402

Reviews.

[Oct.

dence of various travellers ; but the most conclusive and complete evidence,
both as to the extent of the practice and the nature of the ingredients used,
has been supplied by the microscope."

In these cases, then, the consumer gets green tea, and various colouring
matters in addition. But in other instances he gets the colouring matters
alone. One branch of the adulterating business in England consists in buy-
ing up tea-leaves which have been already used and exhausted, drying them,
colouring them artificially, adding sulphate of iron or catechu to restore the
astringency, and reselling them as black or green tea. The colouring matters
employed for this purpose Dr. H. found to be frequently more injurious than
those used by the Chinese ; viz., rose pink, Dutch pink, chromate of lead,
Venetian red, soapstone or French chalk, carbonate of lime, carbonate of mag-
nesia, carbonate of copper, arsenite of copper, Prussian blue, and indigo.

Coffee is adulterated with chiccory, roasted flour, scorched peas and beans,
roasted carrots, mangel-wurzel, acorns, mahogany sawdust, burnt sugar, Vene-
tian red, and baked livers. This last article is one so little likely to be sus-
pected beforehand, that we give a short description of the process, quoted by
our author from a work on coffee, published four or five years since.

"In various parts of the metropolis, but more especially in the east, are to
be found liver bakers. These men take the livers of oxen and horses, bake
them, and grind them into a powder, which they sell to the low-priced coffee-
shop keepers, at from 4<3. to Qd. a pound, horse's liver coffee bearing the highest
price. It may be known by allowing the coffee to stand until cold, when a thick
pellicle or skin will be found upon the top. It goes further than coffee, and is
generally mixed with coffee, and other vegetable imitations of coffee."

Why baked livers should be especially selected for this purpose does not at
first sight appear. It is evident enough, however, as soon as we have become
a little familiar with the "fundamental principles" of adulteration. Horses'
and bullocks' livers are, in the first place, cheap. Secondly, the biliary mat-
ters with which they are imbibed serve to imitate tolerably well the colour
and bitterness of real coffee. They are therefore much better adapted for this
purpose than other internal organs, such as the spleen, kidneys, or brains.
Coffee, again, which has been largely adulterated with scorched flour or beans,
has its colour and bitterness partly restored by the addition of burnt sugar. .

We subjoin, as a curiosity in its way, the following, from page 119 : —

Besults of the microscopic examination of thirty-four different Coffees, of all quali-
ties and prices, and sold under the following attractive titles: —

COFFEES OF HIGH PRICE.

1. Finest Mocha Coffee. No adulteration.

2. Noted Old Mocha. No adulteration.

3. Finest Jamaica Coffee. No adulteration.

4. Rich Old Mocha. Of chiccory, a good deal.

5. Best Old Mocha. A little chiccory.

6. Fine Old Turkey Coffee. Much chiccory.

7. Very Fine Mocha. Much chiccory.

8. Genuine Old Mocha. A little chiccory.

9. Finest Turkey Coffee. Contains chiccory.

10. Celebrated Old Mocha. A good deal of chiccory.

COFFEES OF MEDIUM PRICE.

11. Costa Rica Coffee. Nearly one-half chiccory.

12. Fine Jamaica Coffee. Contains a considerable quantity of roasted corn.

13. Delicious Coffee. Roasted beans and chiccory, forming about one-third
of the article.

1857.] Hassall and Marcet, Adulterations in Food and Medicine. 403

14. Plantation Coffee. Of roasted corn much, with some chiccory, both not
less than one-third.

15. Finest Turkey Coffee. Much chiccory, and some roasted corn ; very little
coffee.

16. Celebrated Jamaica. Very little coffee ; principally chiccory.

17. Finest Berbice Coffee. About one-half coffee, much chiccory, and some
wheat.

18. Splendid Turkey Coffee. About one-half coffee, the rest chiccory.

19. Fine Plantation Coffee. One-third coffee, the rest chiccory, with a little
roasted corn.

20. Beautiful Jamaica Coffee. Two-thirds coffee, the rest chiccory, with a
little corn.

21. Finest Java Coffee. Half coffee, much roasted corn, with a little chiccory.

22. Superior Plantation Coffee. Three-fourths coffee, the remaining chiccory.

COFFEES OF LOW PRICE.

23. Fine Mountain Coffee. Four-fifths coffee, one-fifth chiccory.

24. Parisian Coffee. Principally chiccory and corn ; very little coffee.

25. Superb Coffee. The principal part corn and chiccory ; very little coffee.

26. Rich Drinking Coffee. One-third coffee, the rest chiccory, with some
roasted corn.

27. Very Excellent Coffee. One-half coffee, the other mostly chiccory.

28. Delicious Family Coffee. One-fourth coffee, three-fourths chiccory.

29. Fine Ceylon Coffee. Very little coffee, a great deal of chiccory, some
roasted corn.

30. Fine Java Coffee. Much chiccory and some roasted potato ; very little
coffee.

31. Coffee as in France. Principally chiccory.

32. Very Excellent Coffee. Principally chiccory.

33. Fine Plantation Coffee. Nearly all chiccory ; very little coffee.

34. Delicious Drinking Coffee. A large quantity of chiccory, and much
roasted corn.

Cocoa, sugar, honey, milk, flour, butter, lard, arrowroot, and their adul-
terations, are all described in a similar manner. With many new and unsus-
pected adulterations, discovered by Dr. Hassall, there are some, popularly
supposed to be very common, which he shows to be either quite rare, or even
not to have an existence. Thus sugar is generally thought to be extensively
adulterated with sand ; but Dr. H. found no sand in over one hundred samples
of sugar which he subjected to examination. The impurities which he met
with were starch, treacle, glucose, fragments of sugar-qane, fungous sporules,
and specimens of the acarus sacchari. Milk, again, very seldom contains
chalk, contrary to the general belief. Dr. H did not meet with it in a single
instance. The most prevalent and important adulteration of milk is with
water ; after which the operator adds molasses or syrup to sweeten it, salt to
give it a flavour, and anatto to colour it. Starch and sheep's brains are some-
times added, in order to restore the opacity to diluted milk ; but these adul-
terations are rare, the dealers not usually taking the trouble to practise them.
These impurities would furthermore, like chalk, be at once detected, on allow-
ing the milk to stand, by subsiding to the bottom of the vessel as a visible
deposit.

A very amusing chapter is that on what the author calls "proprietary ali-
mentary preparations;" that is, various mixtures which are prepared of cheap
ingredients, patented, and then sold at a dear rate under some high-sounding
title; such as Kevalenta Arabica, Nutritious Farina, Semola, Semolina, and
the like. These substances consist mostly of baked flour, or even of cheaper
ingredients, sometimes scented and coloured, and sold at prices varying from
twenty-five to sixty-eight cents per pound ; their real value, according to their

40 i

Reviews.

[Oct.

composition, not exceeding in any case five or six cents per pound. Thus the
author gives analyses and microscopic drawings of the following of these ar-
ticles among others : —

Dubarry's Revalenta Arabica; consisting of starch-granules of the Arabian
lentil, barley flour, sugar, and salt.

Wharton's Ervalenta; consisting of a mixture of the French or German
lentil with a substance resembling maize or Indian corn meal.

Gardiner's Alimentary Preparation; consisting of very finely ground rice.

Leath's Alimentary Farinaj or Homoeopathic Farinaceous Food; consist-
ing principally of wheat flour, slightly baked, sweetened with sugar, together
with potato starch, Indian corn meal, and tapioca.

Bullock's Semola ; consisting of the gluten of wheat, with a proportion of
wheat starch.

Maidman's Nutritious Farina; consisting entirely of potato flour, arti-
ficially coloured of a pink or rosy hue.

Plumbe's Improved Farinaceous Food; composed of bean or pea flour,
some potato flour and a little arrowroot.

Palmer's Vitaroborant ; consisting of a mixture, sweetened with sugar, of
wheat flour with the red or Arabian lentil.

The flour, sugar, &c, were introduced, in many of these preparations,
merely to diminish the strong flavour of the lentils, which is sometimes dis-
agreeable.

"Extremes meet," says the author; " lentils, being somewhat cheaper than
peas, are supplied to many of our workhouses, to be used in the preparation
of soup, &c. Thus they are not only consumed by paupers, but by the rich,
the chief difference being that the latter frequently pay 2a. 9d. per pound for
them."

Dr. H. suggests also one or two receipts for preparing similar mixtures,
which shall have all the advantages of the patented articles, if any such
there be, without their exorbitant price.

" As the cost of most of the prepared lentil powders sold as ervalenta, reva-
lenta, &c. — viz., 2s. 9d. per pound — forms a very serious obstacle to their use,
supposing that it is in any respect desirable that they should be more gene-
rally consumed, we have framed the two following receipts, whereby a consi-
derable saving of expense may be effected : —

1st Receipt.

Red or Arabian lentil flour .... 2 lbs.
Barley flour . . . . . . 1 lb.

Salt . . 3 oz.

Mix into a uniform powder.

" The red lentil may be obtained of almost every corn chandler at about Ad,
per quart ; the cost of our ervalenta would be about 2d. per pound ; and it is
perfectly clear from the analyses which we have given above, that whatever
may be the advantages possessed by the much vaunted ervalentas, revalentas,
&c, that our article must contain them all."

2d Receipt.

Pea flour 2 lbs.

Indian corn flour . . . . . . 1 lb.

Salt 3 oz.

Mix as before.

Increase of bulk is not the only object for which adulterations are prac-
tised. We have already seen that, in the case of teas, foreign and sometimes

1857.] Hassall and Marcet, Adulterations in Food and Medicine.

405

poisonous substances are added merely for the sake of improving the colour
and external appearance of the article. This is still more remarkable in the
case of pickles. These articles of food are almost universally more or less
artificially coloured, and generally with some preparation of copper. This
adulteration is sometimes so excessive as to be readily detected, even by the
eye. Every one must have noticed samples of pickles kept for sale by the
grocer, in which the green colour was unnaturally strong; the preserved pickles
being often, in fact, greener than the same vegetables when in a fresh condi-
tion. This green colour has even sometimes a distinct and altogether unna-
tural shade of blue. Now, in all these instances, the colour depends upon
the presence of some salt of copper; either the sulphate (blue stone) arti-
ficially added, or the acetate produced by the action of the vinegar on metallic
copper. When metallic copper is used, the sulphate is frequently formed as
well as the acetate, owing to the previous adulteration of the vinegar with
sulphuric acid.

The examination of twenty-three samples of pickled vegetables led Dr. H.
to the following conclusions : —

1. That the vinegar used for pickling is of a very weak description, the
percentage of acetic acid ranging between 1.48 and 2.91. It will be remem-
bered that vinegar of good quality ought to contain from four to five per
cent, of pure acetic acid.

2. That nineteen out of twenty of the vinegars submitted to analysis, poor
as they were, yet owed a portion of their acidity to sulphuric acid, the amount
of which varied in the different samples from .38 to 2.52 in the 1000 grains;
the largest quantity of this acid being detected in the vinegars in which the
red cabbages were pickled.

3. That in the whole of the sixteen different pickles analyzed for copper,
that poisonous metal was discovered in various amounts ; two of the samples
contained a small quantity; eight, rather much; one, a considerable quantity;
three, a very considerable quantity; in one, copper was present, in highly
deleterious amount; and in two, in poisonous amounts.

4. That the pickles which contained the largest quantity of copper were
those which consisted entirely of green vegetables, as ghirkins and beans.

The author presents a most repulsive picture of the composition of potted
meats and fish, as subjected tc his examination. These articles are but little
used in this country, but in England they are extensively employed and are
generally regarded as a delicacy. The form of a homogeneous paste is, how-
ever, that which presents the greatest facility for adulteration ; and these
preparations are accordingly found to contain not only such ingredients as
flour and starch, and to be partly made up of inferior qualities of meat and
fish, but to be artificially coloured also, in most instances, with Venetian red
or Armenian bole. These earthy substances are added, according to Dr., H.,
not only for the purpose of heightening the colour of the mixture, but also
to conceal the dirt contained in the brine, in which the fish is imported.

The artificial colouring of sugar confectionary is much worse than the above.
These articles are sometimes coloured all over with the same tint ; and are
sometimes parti-coloured, two or three different tints being applied, for the
sake of ornament, to different parts of the same piece. From the examination
of 141 samples, Dr. Hassall arrived at the following result: —

Fifty -nine were coloured with Chromate of Lead.

Eleven with Gamboge.

Twelve with Red Oxide of Lead.

Six with Bistjlphuret of Mercury (vermilion).

406

Reviews.

[Oct.

Eight with Brown Ferruginous Earths, Vandyke brown, umber, or
Sienna.

One with Indigo.

Tioenty-four with Prussian Blue.

Ten with a mixture of Chromate of Lead and Prussian Blue, making
several varieties of green.

One with Carbonate of Copper.
Nine with Arsenite of Copper.
Four with Carbonate of Lead.

Enough has been said to show the great extent of the above adulterations,
and the abominable consequences that are liable to result from them. It must
be recollected that many of these substances, fraudulently introduced into food,
are actually poisonous; and, furthermore, that some of them belong to the
class known as cumulative poisons. The small quantities in which these sub-
stances are introduced, day by day, is therefore no protection against their
finally producing poisonous effects. Whoever takes Cayenne pepper every
day upon his salad, is liable to be dosing himself at the same time with red
oxide of lead ; and the lover of green tea may after a time find his eyelids
swelling and his legs aching from the arsenite of copper with which the leaves
were coloured. Lest it should be supposed that such dangers as these are
altogether imaginary, we subjoin the following account of a case in which
lead palsy was produced by taking snuff; an article which is not unfrequently
coloured with chromate of lead, or the red oxide of the same metal. The
case is given on no less an authority than that of Mr. Erichsen ; and it is of
so remarkable and interesting a character, that we extract it entire. It is
from page 617 of Dr. HassaH's book : —

" Case of slow poisoning by Snuff containing Lead. By Mr. Erichsen. — Whilst
on a professional visit in the country, last March, I was requested to see a gen-
tleman who had been invited down to a friend's country-seat, in the hopes that
change of scene and air would influence favourably an attack of paralysis, which
was said to be of a rheumatic character, by which he had been disabled from
work for many months past, and of which he despaired of recovering, having
relinquished all treatment.

"I found the patient in bed, and somewhat exhausted by the journey down,
a distance of nearly a hundred miles from his usual residence. He was pecu-
liarly sallow, the complexion having almost an icteric tinge ; but the counte-
nance was lively and expressive, and the intellect as bright as usual.

"Mr. A. B. could stand, and, if supported, could walk, though feebly and
with much difficulty. He complained much of pain about the shoulders and
the fleshy parts of the thighs and legs, and especially of burning sensations in
the soles of his feet. The articulations all appeared healthy; no swelling or
looseness was perceptible about any of them.

"I was, however, particularly struck with the appearance of the hands and
arms, which were lying powerless on the coverlid of the bed. There was marked
'wrist-drop' of both arms, the hands hanging flaccid and at right angles with
the forearms, without the patient being able to extend or raise them in the
slightest degree. There was, however, some slight power of extension left in
the fingers, especially in those of the left hand. Though unable to extend the
fingers, raise the hand, and scarcely having power to elevate the arm, Mr. B.
could flex the fingers pretty firmly, so as to give a tolerably good grasp to what-
ever was put into his hand. The index finger of the right hand seemed to be
the most affected, and vas permanently flexed.

" There was a very marked degree of wasting of the whole mass of the ex-
tensor muscles of the forearm, so that a longitudinal hollow corresponding to
the interosseous space was perceptible down the whole length of the forearm,
and a very deep and marked depression in the interspace between the first and

1857.] Hassall and Marcet, Adulterations in Food and Medicine.

407

second metacarpal bones. The hands were quite powerless, and the patient
was unable to render himself the slightest assistance.

" The tongue was pale and flabby ; and on examining the gums, I found a
deep blue-black or leaden-coloured line around the teeth, more marked about
the molars. Digestion was much impaired. Appetite capricious, with much
flatulence, and occasional attacks of constipation, with colicky pains.

"On inquiring into the history of the case, I learnt that Mr. A. B., who is
much devoted to literary pursuits, and habitually led a sedentary life, had for
some years previously suffered from pains of a rheumatic or gouty character;
that in May, 1853, he had been attacked by constipation and colic while lodging
for a short time in a newly-painted house. In August of the same year he had
first begun to lose power in extending his arms, finding a difficulty in raising
them to put on his coat; and from this time the paralytic symptoms gradually
increased, until they had assumed the degree in which I found them, when he
had become reduced to a state of complete physical helplessness ; though, as I
have already observed, his powerful and clear intellect was as perfect as ever.

"On examining Mr. A. B., I was at once struck by the very marked 'wrist-
drop,' more complete than I had ever seen before ; the limitation of the para-
lysis to the extensors, which were greatly wasted ; the existence of a blue line
around the teeth ; and the occurrence of occasional attacks of constipation and
colic, together with flying pains in the fleshy parts of the body, with absence
of all articular inflammation. These symptoms led me to the conclusion that
Mr. A. B. was suffering from saturnine paralysis, and that he had been slowly
poisoned by lead.

" The difficulty was, however, to ascertain how poisoning by lead could have
been effected. With this view, I made diligent inquiry into the patient's habits,
the water he drank, the utensils he used, &c, but could not detect any source
to which the presence of the mineral in the system could be traced, except that
the first attack of colic and constipation had occurred whilst temporarily lodg-
ing in a house which smelt of fresh paint ; but as he soon left this, I thought
it very insufficient to explain his continued and increasing sufferings. In the
course of my inquiries, however, I found that he took snuff in considerable
quantities ; I accordingly emptied his box of its contents, and took them up to
town with me with a view to further examination. The snuff was analyzed by
Professor Williamson, who detected in it a considerable quantity of lead; and
another supply having been procured from the shop at which Mr. A. B. was in
the habit of purchasing it, was subjected to analysis by Dr. Garrod, who rea-
dily detected large quantities of the metal in it.

" Mr. A. B. was now put under treatment for saturnine paralysis. The snuff
was left off; the bowels were kept open with the acidulated sulphate of magne-
sia ; iodide of potassium was freely given in conjunction with strychnia, which
was applied topically to blistered surfaces as well as administered by the hands ;
and galvanism was assiduously employed. Under this plan of treatment he
gradually improved in all respects; the colicky symptoms rapidly disappeared,
the muscular pains subsided, and the paralytic condition of the extensors was
gradually removed, until at the end of July he was able to resume and to dis-
charge public duties of a very onerous character with his usual ability and
energy.

" With the above sketch we received from Mr. Erichsen a sample of the
snuff which was the occasion of all the mischief. On analysis it was found
to contain 1.2 per cent, of red oxide of lead; that is very much less than some
of the other samples, the analyses of which have already been given."

The author goes through, in a similar manner, with the description of
vinegar, spices, cheese, ale, porter, spirits, wines, &c, and their adulterations.
We will not, however, dwell further on the very interesting details which he
presents, but refer the reader for them to the book itself.

In conclusion, we would offer some remarks on the adulteration of food
and medicine in our own country, and the means of protecting ourselves
from it, for which we believe the reader is already prepared. It is plain that

408

Reviews.

[Oct.

the adulteration of food is a serious injury, not to the purse only, but to the
health of the consumer. That of medicine is certainly not less deleterious.
It is always fraudulent and may at any time become even homicidal in its
consequences. By its operation all the devotion, skill, and judgment of the
practical physician are set at naught. A patient has perhaps swallowed, in-
tentionally or by accident, an overdose of laudanum. The physician who is
called finds him already half comatose; and he knows that ipecac and tar-
tarized antimony are too slow in their operation to be trusted as emetics.
Sulphate of zinc is not at hand; and if it were, half of it would, perhaps,
consist of Epsom salts. But there is mustard; nearly always to be found
ready in every family, the most active, prompt, and local in its operation of
all emetics, and the most stimulating to a semi-narcotized stomach. He
mixes a liberal dose, succeeds by dint of perseverance in compelling the pa-
tient to swallow it, and awaits the result. But, unfortunately, the mustard
was partly clay, partly plaster of Paris, and partly turmeric, with a little
real mustard and red pepper to give it pungency. No vomiting follows.
Another dose is forced down, with greater difficulty than before, with a simi-
lar ineffectual result; and by the time the assistant arrives with a stomach-
pump, the patient's blood is loaded with the narcotic, and he is fairly beyond
the reach of help from either medicine or surgery.

Take another instance. A physician wishes to give an emetic to a slender
and delicate child, who has eaten the wrong thing at dinner and is sick in
consequence. Sulphate of zinc or copper would be evidently unnecessary
and inappropriate. Tartarized antimony especially is to be avoided, on ac-
count of its depressing effects and the persistence of its operation. Ipecac,
mild and effectual as an emetic, without any violent depressing constitutional
effects — is the drug which he judiciously selects. But his judgment is with-
out avail; for the ten grains of ipecac administered to the little patient con-
tain eight grains of liquorice and one of tartarized antimony.

Now, let it be remembered that such cases as these are liable to occur at
any moment in the practice of any physician. Similar instances, where the
immediate effects are not quite so disastrous, evidently do occur daily, and do
not require to be especially designated. In view, therefore, of the moral
character, the intention, and the consequences of these adulterations, there can
be but one conviction as to the necessity of legislative interference, and the
manner in which it should be exercised. The adulteration of food or medicine
should be made a felony ; and should be placed upon the same level with the
coining of false money, and the counterfeiting of bank-notes. The dealer who
vends a spurious article, knowing its character, would then be placed in the
position of one who passes a counterfeit bill, knowing it to be counterfeit.
The consumer would then have every reasonable protection. The honest
trader would not be compelled, in self-defence, to adopt the practices of the
unscrupulous, or at least to wink at their existence, as he does at present ;
and, finally, the practical operation of medicines would no longer disappoint
the physician and discourage the patient, as they too often do at the present
day. It is to be hoped that both the National Association and the local
societies will continue to agitate the question, until they succeed in bringing
it properlv under the notice of the State legislatures.

y * * J. CD.

1857.]

Forbes, Of Nature and Art in the Cure of Disease.

409

Art. XIV. — Of Nature and Art in the Cure of Disease. By Sir John
Forbes, M. D., and C L. Oxon, F. R. S., Fellow of the Royal College of
Physicians, Physician to the Queen's Household, &c. &c. : London, 1857,
pp. 264.

This book requires at our hands something more than a brief bibliogra-
phical notice ; for it contains the fullest and most satisfactory development
that we have yet seen of a subject, which has lately attracted extensive and
deep attention from thinking minds in our profession. We do not mean to
say that it is a. perfect book. It has many faults and short-comings, as the
reader will see as we proceed with our review of it. But it is, nevertheless,
so good a book — so full of wise instruction on many of the most important
points in therapeutics, and so clear and forcible in its exposure of many very
prevalent errors in medical practice — that we hope it will be reprinted in this
country, and have a large circulation in the profession, and also among intel-
ligent men in the community at large.

Although the subject of this book is more extensively and systematically
examined here than it has been anywhere else, the discussion of it is very far
from being exhausted. Indeed, it is absolutely necessary that the investigation
should be pushed far beyond those points which Sir John Forbes brings out,
in order that the whole duty of the profession may be compassed, and its
therapeutics be placed upon its right basis. Medical practice is everywhere
still in an exceedingly unsettled state ; and there will obviously be needed
much more and closer investigation of the relations of art and nature in the
treatment of disease, to establish correct views of them in all their compli-
cations. Such labours as those of Forbes in this volume do, it is true, settle
some points; but these are few in comparison with the many that yet remain
to be settled. As we read we are prompted continually to look forward to
the results hereafter to be realized from the observation of disease, carried on
under the influence of the suggestions presented here and in other books and
papers on similar subjects. Great changes in medical practice have taken
place in the last twenty or thirty years from such influences, and we antici-
pate greater still in years to come. The indications of this are not to be mis-
taken. Practical medicine is in one of its great transition periods, and a
more eventful one than has ever before transpired. The glory of the future
of our art is, it is true, seen but dimly; and yet it is seen sufficiently by the
intelligent and earnest physician to awaken him to the most strenuous efforts
for its advancement. That these anticipations are not unfounded we think
will appear as we go on with the examination of the work before us.

Our object in this article is threefold — to aid in diffusing the spirit of the
book and its prominent ideas in the profession ; to point out some of the
errors of the author ; and to induce others to engage in the investigation of
the subject. In regard to this latter point, as already hinted, it is plain that
we are as yet at the mere threshold of all that is to be discovered and set-
tled. Although much has been written on the subject, both formally and
incidentally, in book and in pamphlet, especially of late years, there is much
more to be written ; for it is in the investigation indicated that therapeutics
is to find its chief means of advancement. It is to the discovery of the capa-
bilities of nature and of the proper limitations of art in the cure of disease that
the attention of physicians at the present time should be principally directed.

410

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[Oct.

In the introductory chapter, Sir John Forbes speaks of his book in the
following very appropriate language : —

" Having been now actively engaged in the practice of Medicine for the long
period of fifty years, and having derived therefrom much of the prosperity and
happiness that have been my fortunate lot in life, I feel that my profession has
claims on me for much more than I have hitherto been able to give it; and as,
at my time of life, and in my present state of health, I have no right to look
forward to the acquisition of further knowledge in the same field, it is incum-
bent on me to communicate now any information I may possess, if I am to
communicate it at all, In doing so, I cannot help being impressed with the
feeling of solemnity which naturally accompanies any act that is to be the last
of its kind. And, in this mood, I would fain regard the present work in the
light of A Legacy to my Younger Brethren, which, slight as it is, may not be
found altogether unworthy of their acceptance. I would, indeed, bequeath it
in full confidence of its value, if I might reckon on its being received in the
same way as the legacy of the Pot of Gold, in the fable, was received by the
rustic testator's sons. If my book — though, like the old man's vineyard, really
containing in itself no gold — should only lead to the zealous cultivation of the
subject of which it treats, the result could not fail to be of inestimable value
to the cultivators. For, on the profounder, more critical, and purer study of
Nature, as manifested in disease, rest, in my judgment, the best hopes of im-
provement in the medical art ; and to this study the spirit of my book may, at
least, lead the way and give the initiative, if its actual contents are found of
lesser importance."

We wish that the profession had more of such legacies. Though we would
be far from encouraging any great number of physicians to give to the public
in their old age the lessons of experience which they have gathered, from a
fear of a predominance of garrulity in our medical literature, we wish that
we had more of such works as this of Sir John Forbes, the Medical Notes
and Reflections of Sir Henry Holland, and the Letters to a Young Physician,
by Dr. James Jackson, of this country.

Our author has not written this book for the profession alone — he wishes
to enlighten intelligent and thinking men in the public at large.

In relation to this our author very justly remarks : —

"It cannot be doubted that juster views of the nature of medical science
and of medical art, if once prevalent among the lay public who are well in-
•formed, will, like all other knowledge, descend to those who are not so; and
thus the progress of rational medicine will be facilitated, and the hands of
those professors strengthened, who have the courage to advocate and practise
their art conscientiously, however opposed to vulgar prepossessions and preju-
dices."

The practicability of any such effort to enlighten the public is doubted by
some physicians. They claim that the subject of practical medicine is of so
difficult and complex a character, that no one can understand it who does
not make it the study of his life ; that, therefore, all attempts to explain its
principles to men out of the profession will prove futile ; and that the public
must learn to take physicians wholly upon trust, aad not inquire into their
practice. But this is going altogether too far. While we would have non-
medical men appreciate most fully the difficulty of understanding therapeu-
tics, and deny them the right to sit in judgment on the practice of the phy-
sician simply because they are incompetent to do so; we believe that there is
a common ground, and one of no narrow limits, on which physician and pa-
tient can meet and act together in the cure of disease. And we believe that
this common ground will be constantly widening, as medical practice shall be
stripped of its needless mystery, and be rendered more consonant with nature

1857.] Forbes, Of Nature and Art in the Cure of Disease. 411

and plain common sense, and as thinking men in all classes of the community
shall become properly informed through the efforts of physicians, who, like
our author, are willing to take the paios to teach them what it is possible for
them to understand on the subject. There is much, it is true, in medicine
that is necessarily mysterious to the practitioner, and much more that is so
to the non-professional observer ; but this furnishes no reason for shutting
out the latter any more than the former from learning what he is able to
comprehend.

The time for implicit blind trust in the physician has gone by, and we are
glad that it is so. Be it that there are numerous errors floating in the public
mind, arising out of its disposition to opinionate on medical subjects. We
had rather have this than stagnation, for it is a state of transition leading to
something better. This mental activity on the part of the public in relation
to medicine is not to be forever breeding error. It can be enlightened, and
thus be brought into the service of the physician. But so long as it is not
enlightened, it will be retained in the service of the quack and the quackish
practitioner, and will thus continue to prove a serious obstacle to the advance-
ment of our profession. The duty of medical men then is clear. If they
desire to promote, the interests of medical science, they must enlighten the
public, so far as it can be done, in relation to the principles on which they
act in the treatment of the sick. In truth, this has already been done to a
considerable extent both by public and private efforts. A great amount of
information on medical subjects has been scattered by phvsicians among the
people, especially during the past twenty or twenty-five years. To say no-
thing of other publications, the exposures which have been made of homoeo-
pathy and other forms of quackery, have taught intelligent men in the com-
munity much in regard to the principles of medicine. And then in the pri-
vate intercourse of physicians with their patients and friends a vast deal has
been done in the removal of error and the diffusion of truth.

It would take us into too wide a field if we should notice all the evidence
that we have that this enlightenment of the public mind has been thus in
progress. We will allude to but one fact — one which every intelligent phy-
sician must observe in his daily intercourse with his patients. It is the fact,
that the number of those with whom he can deal plainly and without the
disagreeable necessity of a resort to placeboes, whenever he deems it proper to
give but little or no medicine, is continually increasing. This would not be
so if there were not a gradual diffusion of the principles of rational medicine
in the minds of the people.

We would have these efforts, both private and public, for popular enlight-
enment in regard to medicine still plied by phvsicians as opportunities offer
for doing so. Our chief business, it is true, is the improvement of our art;
but at the same time we can, with profit alike to ourselves and the commu-
nity, diffuse rational views of medicine among the people, by efforts of an
incidental character. Especially, can this be done in our daily intercourse
with patients. It is true in this as it is in everything else, that more is ac-
complished for the general good by the aggregate of little, or rather limited
influences, exerted by the many, than by the greater and more public efforts
put forth by the few.

We have been led into more extended remarks on this point than we in-
tended to make; but the subject is so important that we should be glad to
dwell upon it longer if our limits would permit.

Our author, in speaking of the object of his work, says that it

412

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[Oct.

"Is not simply to exhibit, in an independent manner, the general fact of the
respective and relative powers of Nature and Art in curing diseases, but to
establish the more special fact that Nature possesses vastly greater powers
than Art in curing diseases, and, consequently, that its extent is beyond the
common belief of the junior classes of medical men, and men in general."

In proving this general proposition, he treats in separate chapters of many
subordinate topics such as these : the ignorance existing respecting the power
of nature to cure diseases ; general notions of diseases ; the abuses, mode of
production, and nature of diseases ; the cause and progress of diseases ; the
natural terminations of diseases, and the modes in which they take place ;
evidence in favour of the curability of diseases by nature ; the existence and
general nature of the medical art ; instruments of the medical art ; the direct
and specific action of some of these instruments, and the indirect and vicari-
ous action of others. His concluding chapter contains a general estimate of
the powers of the medical art.

Here we have a wide range of topics, and all of them are treated very fully,
the author bringing out freely the results of his experience, covering the space
of fifty years. We think that the best chapter in the book is that which
treats of " the evidence in favour of the curability of diseases by nature."
The evidence on this point is brought out very copiously and clearly under
eight different heads. The conclusion at which he arrives is thus expressed : —

" The one great result obtained from the study of these various authorities
is this : that the power of nature to cure diseases is infinitely greater than is
generally believed by the great body of medical practitioners, and by the
public generally. So great, indeed, is this power, and so universally opera-
tive, that it is a simple statement of the facts to say, that of all diseases that
are curable and cured, the vast majority are cured by Nature independently of
Art ; and of the number of diseases that, according to our present mode of
viewing things, may be fairly said to be cured by Art, the far larger portion
may be justly set down as cured by Nature and Art conjointly. The number
of diseases cured entirely by Art (of course I omit, in all these statements,
surgical art), and in spite of Nature — in other words, the number of cases that
recover, and would have died had Art not interfered, is extremely small."

Some may be disposed to doubt the correctness of the last statement in this
summing up of the author's conclusions. But we think that it is sustained
by the most abundant proof. Besides that which is adduced by Sir J ohn
Forbes, we would allude to a grand fact which stands out very prominently,
as we take a survey of the contentions, both in and out of the profession, in
relation to the comparative efficacy of different remedies and modes of practice.
It is the fact that a show of success is made out by the advocates of each of
these rival remedies and modes. What is the explanation of this ? Simply
that the difference in the results is so small that it is difficult to ascertain it.
It cannot be ascertained without both an extensive and a minute examina-
tion of the facts ; and such an examination can seldom be had. The reason
of the smallness of the difference is to be found in the ever present and effect-
ive agency of the recuperative power, which almost always towers above all
the instrumentalities of art, and has so much to do with the cure of disease
that, whether these instrumentalities have much power or little or none, there
is no palpable difference in the gross results. When our therapeutics shall
become what it should be, by the investigation which is now going on in re-
gard to the relations of Nature and Art in the treatment of disease, the dif-
ference between good and bad practice will be more easily seen than it is
now, simply because it will be so much greater. And yet, however great
shall be the improvement in the prevalent practice of educated physicians,

1857.] Forbes, Of Nature and Art in the Cure of Disease. 413

the difference between its results and those of bad practice, whether ridicu-
lously inert, as Homoeopathy, or shockingly active, as Thompsonianism, will
never be so great as to forbid a false show of success on the part of the advo-
cates of quackery.

It would be interesting to pursue this subject further, for it presents
numerous points which it would be profitable to discuss, but we pass on to
other topics.

The great object of our author is to prove the extent of Nature's power in
the cure of disease. This is well, but it is not enough. -Unless the investi-
gation be carried beyond this point, there will be great liability to error. A
license may be given to an indiscriminating reliance upon nature. Here we
think is a decided failure in the work of Forbes. To guard against the error
indicated should have been quite a material and prominent point with him.
It is true that he has much to say about watching Nature and rendering
assistance to her efforts whenever it is necessary j but he does not treat this
point with the force and emphatic distinctness which it merits. The indolent
in the profession who ordinarily satisfy themselves with a routine practice,
will find the same ease, on becoming convinced of the truth of Sir John
Forbes' s views, in resigning their patients for the most part into the hands of
Nature. There is nothing in his book calculated to impress upon them the
imperative duty of a strict watch, for the purpose of securing every oppor-
tunity that may offer for an advantageous interference of Art. This is a
material defect. For, although Nature is the chief agent in the cure of dis-
ease, and the duty of the physician is therefore for the most part to watch
for the purpose of gently assisting her operations, yet it is a great neglect of
duty if he let slip any of the opportunities that occasionally present them-
selves of effecting decided changes for good by active medicine.

This defect in our author's presentation of the subject is seen in the view
which he gives of different modes of practice. He reckons four prevalent
modes.

1. Extinguishing Treatment. The object in this mode of treatment "is to
cut short, as it is called, or extinguish diseases by a bold stroke, or coup de
main, applied to them, or rather to the system, in their earlier stages." The
grand means of doing this are bloodletting, emetics, purgatives, the cold bath,
&c. Of this treatment he well remarks that

" In rare instances the violent artificial disturbances excited in the system seem
to overcome the natural disturbances existing in it; but, as a general rule, the
indication is not only not fulfilled, but the existing disease is either aggravated
directly, or the natural restorative powers of the system are arrested, enfeebled,
or misdirected."

Though this mode of treatment was once in quite common use, our author
says very justly that it " is to be abandoned as one of the forms of general
practice ; or, if employed at all, only to be so in very special and exceptional
cases."

2. Active Treatment. In this mode the same means are used as in the
first mode, but in a less active and more continuous manner, the object being
to diminish materially the intensity of disease and check or retard its pro-
gress. This practice, formerly so prevalent, has become much modified of
late, many of its advocates having " abandoned several of its most heroic
weapons." In relation to this our author says that " the value of the practice
increases in proportion as it recedes from the high heroic, and approaches the
level of the more patient and humbler modes of practice to be noticed under
the next head."

414

Revievjs.

[Oct.

3. Auxiliary or Mild Treatment: rational expectancy. This system of
treatment " recognizes the autocracy of nature in the cure of acute diseases,
and proceeds on the principle that it is not only useless, but injurious to
attempt to suppress or greatly to modify the morbid processes by strong mea-
sures of a perturbative or exhaustive kind." Sir John says further : —

" In attempting to estimate its value as one of the representative forms of the
medical art, I would say that, while it possesses a very positive superiority
over all the plans of treatment which, whether intentionally or not, virtually at
least, leave Nature to her own resources, it presents an equal superiority over
all the plans that endeavour to supersede Nature's proceedings altogether, by
substituting for them the operations of Art. It occupies the lofty medium be-
tween doing too little and doing too much."

4. Negative or totally Inert Treatment : pure expectancy. While Homoeo-
pathy— that is, so long as it adheres to its infinitesimal doses — is an example
of this mode of treatment, " in all the times of Physic it has been adopted, in
a more or less rigid form, by many wise and experienced men and, adds
our author, " I, for one, while disapproving it on principle, am disposed to
think that it has fared worse with the sick since it was entirely set aside for
the heroic system of treatment which has been so long prevalent."

In reading the remarks which Sir John Forbes makes in regard to these
modes, the impression which we get of the comparative practical estimate
which he puts upon them is in some respects indefinite. While there are
some expressions which would lead us to think that he would admit the three
first, or at least the second and third, into his practice, giving, however, a
most decided prominence to the third, he certainly places them in strong con-
trast with each other, and speaks of the third as the one which he has long
preferred, conveying the idea that he had discarded the others. He should
have been more explicit. If he relies chiefly on the third mode, with an oc-
casional admixture of the second, and little or none at all of the first, he
should have said so. And if he had said so, we think that he would have
stated the truth in regard to the comparative value of these modes. He
should have gone further than this. While he condemns in glowing but just
terms an exclusive heroic practice as so disastrous, that patients had better be
wholly consigned to Nature's care than be subjected to its perturbing and ex-
hausting processes, he should caution most positively against an entire aban-
donment of this mode, and should enjoin upon the practitioners that listen
with such deference to the wise lessons of his abundant experience the im-
perative duty of resorting to active treatment whenever it is clear that it will
aid in the recovery of the patient.

Another defect which we find in our author is the want of a proper appre-
ciation of our means of acquiring a knowledge of therapeutics. In various
parts of his book he speaks of the necessity of a Natural History of Diseases ;
that is, a description of diseases as they would appear in their various stages
without any influence from remedies. He thinks that ignorance on this sub-
ject, which he believes to be exceedingly prevalent in the profession, is u the
grand fundamental obstacle to the attainment of a true appreciation of the
powers of Art," and cites the following as the chief causes of this ignorance : —

" 1. The first and most important of these causes, is the defect existing in
all medical schools, of having no distinct chair for instruction in the Natural
History of Disease, and the consequent neglect of it, or very inadequate atten-
tion given to it by the professors of Pathology, Physiology, and of the Theory
and Practice of Medicine, in whose courses alone any consideration of it could
be expected.

1857.] Forbes, Of Nature and Art in the Cure of Disease. 415

" 2. Another and equally important cause is the impossibility of young men
being able to prosecute by themselves such a study, while still students,
owing to there being no open field for it in hospitals or dispensaries; every
case there presenting itself being seen under the influence of medical treat-
ment.

"3. Again, great difficulties exist in the way of the hospital or private
practitioner, of creating for himself a proper field for such a study. Of these
difficulties we need only here notice the following: a. The practitioner's own
conscientious scruples against leaving any cases to the unassisted care of
nature, from natural doubts or fears — magnified by his previous teaching —
that he might thereby be injuring his patients or even endangering their lives.
b. The non-conviction or non-perception of the utility of the knowledge to be
so acquired, preventing the suggestion of such trials; a natural result of his
previous education, which inculcated the exclusive action of art in the cure of
diseases, c. The dread of being exposed to the charge of mal-practice or
dangerous practice, in the eyes of his pupils, or brethren, or patients, if he
omitted the ordinary remedies in severe diseases, and trusted to the natural
restorative powers of the system.

" 4. It will also be admitted that since the great increase of charitable medical
institutions in all parts of the country, it is not easy to meet with cases, even
among the lowest classes, entirely left to nature ; while, from the natural in-
stinct to seek relief from suffering, the rich of all ranks almost invariably
place themselves under some sort of treatment, regular or irregular ; and there
is never found any deficiency of practitioners of both classes who are ready to
give their services.

" 5. Finally, we must not pass over, as an uninfluential cause, the inability
of practitioners, from prejudices of education, to see in cases treated by them
with remedies either inert or adverse to a cure, the results of the spontaneous
operations of nature, whether favourable or unfavourable ; and the consequent
inability to profit by the examples before them."

Much of all this is true, but some of it we dissent from most decidedly.
We think that to some extent a false view is presented of the objects and
modes of medical observation. We do not believe that it is right for a phy-
sician to forego, in any case, the use of positive medication where it is clearly
applicable, merely for the sake of seeing how the disease will proceed under
the guidance of nature alone. It is his duty to his patient to use all the
means which can do him good. And we do not believe that any neglect of
duty is required in any case for the purpose of accomplishing the object con-
templated by Sir John Forbes. A knowledge of the natural history of dis-
eases can be acquired without any such objectionable means. In mild cases,
requiring almost no treatment, and in severe cases treated with inert remedies,
falling under our observation accidentally, we can observe the uninfluenced
morbid processes in such a way as to make out the natural history of diseases.
And some, nay much assistance can be derived from cases which are subjected
to treatment. In order to know what nature can do, it is by no means abso-
lutely necessary to leave cases entirely to nature. The interference of art,
even when quite decided, is compatible with the acquisition of this knowledge.
And after all, what the physician most wants to know is, not what nature can
do alone, but how nature and art can work together in the cure of disease
It is to this point especially that his observation is to be directed.

The proposition which Sir Johu broaches of having a chair devoted espe-
cially to instruction in the natural history of diseases, distinct from the chair
of practical medicine, is therefore wholly unwarrantable. There should be
no such separation between the observation of disease left to nature and that
of disease treated by remedies. Therapeutics, though wide in its range, is
indivisible. It comprises both nature and art, and its success depends upon

416

Reviews.

[Oct.

a knowledge of their relations to each other in the cure of disease. Indeed,
it can claim the resources of nature as its own, for its duty is to use and to
regulate the natural agencies, to remove any obstacles that hinder their ope-
rations, and to supply their deficiencies. It can be called no invasion of the
domain of nature for therapeutics to enter it. There, indeed, must be the
great field of its labour, where it must for the most part co-operate with na-
ture, but sometimes modify her movements, and now and then oppose and
subvert them. It is only this broad view of the office of therapeutics that
will insure the thorough and effectual investigation which will redeem our art
from its uncertainties, so far as it can be done, and place it upon its proper
basis. No partial views, however much of good they may accomplish, can
lead to this grand result.

Another defect in this book is its failure to indicate the rules which should
guide the investigations of physicians in discovering the complicated relations
of nature and art in the cure of disease. The author has confined himself
too much to the bare demonstration of the power of nature. He has laboured
well in exposing error, but has not done as much as he ought in establishing
truth in its place. He has shown most clearly that much of the practice still
in vogue in the profession is not only useless, but positively injurious ; but
he has failed to point out, with sufficient compass and definiteness, the prac-
tice that should be substituted for it. He has introduced into the mind of his
reader large but rather vague ideas of the curative powers of nature ; but in
relation to the power of art, he has done little else than inculcate cautions
against any busy interference on her part. What the practitioner wants to
know is, not merely that nature has great power, but in what ways he can
co-operate with her, and under what circumstances it is right for him to inter-
fere with her operations. Hints, it is true, are thrown out on these points
(quite freely on the first point, but very faintly on the second) ; but the author
should not have been satisfied with this — he should have made the points in-
dicated prominent in his book, and showed definitely what rules should guide
the physician in determining the limitations of art in each individual case, as
it presents itself for his treatment. Failing to do this, Sir John Forbes
leaves the subject somewhat at loose ends, and so the good service which he
will render to the profession will be more limited than it otherwise would
have been.

The author deserves the thanks of the profession for his clear and forcible
exposure of some of the errors which have hindered and still hinder the pro-
gress of our art. We will give here an example of his mode of dealing with
such subjects. There is one kind of practice very prevalent which he denomi-
nates the pseudo-specific treatment. The error of those who follow this plan
consists in supposing what is true of a few remedies in relation to some dis-
eases to be true of all the prominent remedies, and in relation to a great
number of diseases. Of this error the author thus remarks : —

" In no department of science or art, in no phases of human action involving
ratiocination and inference, are more false grounds admitted or more false con-
clusions drawn, than in this case ; and the practical results are such as might
be expected to flow from such a source. Every drug that has at any time been
regarded by anybody as possessing some special power, either in curing dis-
eases or in influencing the functions of the organs in which they are supposed
to have their seat; every drug that has been recommended by anybody, more
especially by authors and teachers, simply as beneficial in certain diseases,
though on no better evidence than that it was employed in cases that reco-
vered ; every drug that has been proposed by writers as of probable or even
possible utility, on mere theoretical grounds ; every drug that has been sug-

1857.]

Forbes, Of Nature and Art in the Cure of Disease.

417

gested by analogies, however vague ; every drug that has not been previously
prescribed in the particular disease in hand ; in a word, almost every drug in
our overflowing Materia Medica, whether- inert or active, has been, on some
ground or other, copiously prescribed in every variety of disease, under the
supposed sanction of this pseudo-specific or empirical indication."

This kind of practice, Sir John says, " is at this very time in as great vogue
as ever, although its employment may be often veiled under the technicalities
of newer science. Nor is it confined to the ignorant or inexperienced among
us, but adopted and followed by men of the greatest abilities and greatest
eminence in the profession." This must be an over-statement. We know
that it is not true of the profession in this country, and though the profession
in England is not advanced as far as it is with us in casting off the over-
drugging system of practice, so much in vogue some twenty-five years ago,
we must believe that it is an over-statement in regard to British physicians.
Here, also, is another statement, the strict truth of which we doubt. After
speaking of advances which have been made in medicine, our author says :
" It is very remarkable, however, that in regard to one most important part
of the history of diseases, that, namely, of their natural course and event,
infinitely less progress has been made ; insomuch that it may now be affirmed
that the practitioners of the present day are, speaking generally, almost as
uninformed in this particular as were their predecessors fifty or a hundred
years back." We hardly see how he could have been led to make such a
statement. To say nothing of other diseases, do the profession at large know
nothing more of the natural course of the exanthemata and other maladies to
which Bigelow has applied the appropriate term " self-limited'7 than their
predecessors did ?

The truth is that Sir John Forbes, in his eagerness to make out his points,
is rather prone to over-statements. He has shown this before in his famous
article on " Homoeopathy, Allopathy, and Young Physic," published in
1845. Among other things which he said, he uses this language about the
general condition of practical medicine at that time : " Things have arrived
at such a pitch that they cannot be worse; they must mend or ejid." So far
from this being true, things were at that time past their worst — perhaps we
may say far past it — and were rapidly mending. Many, very many thinking-
minds in the profession had before that time discarded the prevalent heroic
medication, and were exerting a great influence upon medical men generally.
It is true that the article of Sir John (then Dr.) Forbes was not very well
received by the profession generally; but it was not because he told them
wholesome truths. It was rather because, in his earnestness, he often went
beyond the strict truth, and especially because, in doing so, he made some
unwarranted admissions in regard to Homoeopathy and the founder of that
master- piece of delusion and quackery. When he asserted that Hahnemann's
name " will appear in the history of medicine in the same list with those of
the greatest systematists and theorists," and actually associated it with the
names of Stahl and Boerhaave; and when he further said that his system of
medicine was " destined probably to be the remote, if not the immediate
cause of more important fundamental changes in the practice of the healing
art than have resulted from any promulgated since the days of Galen himself,"
it is no wonder that the profession generally should be offended by opinions
so palpably groundless, and should therefore receive with suspicion the senti-
ments of him who uttered them. But notwithstanding he thus unnecessarily
awakened opposition in the minds of the profession, all that is true in that
article was appreciated by all rational physicians, and the article had really
No. LXVIIL— Oct. 1857. 28 .

418

Reviews.

[Oct.

a decided influence in hastening the downfall, then already begun, of the
reign of heroic medication. And the work before us, although it has many
defects, will do vastly more than his article did towards effecting this object.

Although Sir John Forbes puts the name of Hahnemann, that wildest of
all medical dreamers, in the same category with that of Stahl, he in one part
of his book eulogizes Stahl, and says of him that " his works contain more of
original truth in regard to the nature and treatment of diseases, and in regard
to the proper method of studying them, than any other writings of his time."
He says, also, that the system of treatment which he advocates is exactly
that which Stahl recommended a century and a half ago — viz., that of mild
auxiliary treatment, or rational expectancy. It would seem that Sir John
really laments that the inert practice of the times of Stahl, with its mass of
complex and inefficacious compounds, ever gave way to the active medication
introduced by Cullen and his immediate successors. It may be that the change
was not immediately beneficial; but we have no doubt that it has been
remotely so. In order to place therapeutics upon a rational basis, it was ne-
cessary that it should pass from the inert polypharmacy of the times of Stahl
through a stage of undue activity. A too large use of powerful remedies was
a necessary evil, incidental for a time to the introduction of these remedies to
the knowledge of the profession. The result is, that these remedies, used too
freely at first, from the very fact that they are so valuable, are now coming to
be used with the proper discriminations ; and their value is such, that we have
no hesitation in saying that the substitution of the judicious use of them for
the aimless and frivolous polypharmacy of the times of Stahl, is worth vastly
more than has been paid for it in the evils which have been induced from the
heroic medication through which the benefit has come. At any rate, we do
not believe that even Sir John Forbes would seriously advocate our going
back to the Stahlian practice, with all its encumbrance of useless material,
and its opposition to the use of such remedies as cinchona and opium.

"We would remark, in this connection, that we hope there will soon be an
end to purchasing experience at so dear a rate as has been usual in our pro-
fession. It is time that more strict and rational rules of investigation should
govern in practical medicine. There should be vastly more caution in the
use of all remedies than is common with the great majority of medical men.
Especially should this be so with all new remedies. The habits of the pro-
fession generally need to be entirely changed on this point. It is the dictate
of common sense that a new remedy should be used sparingly at first, and its
operation should be submitted to the closest scrutiny, before it be brought
into extensive use in the profession. But the reverse of this has been the
case with most physicians. It is the few only that have been cautious at the
outset. Accordingly, every new remedy has at once, immediately after its
announcement, been brought largely into use ; and after experience has been
had, either of its inefficucy or of the dangers attendant upon its power, its
use has become limited, or has been given up. So, too, for the same reason,
the young physician generally uses medicines with a free hand; but as he
grows older, his experience of their results leads him to greater and greater
discriminations and limitations in their employment. This, too, should be
reversed. The young practitioner, with his limited practical knowledge of
medicines, has need of more caution than is necessary after he becomes
thoroughly acquainted with the effects of the means which he employs. The
range of his medication should rather widen than narrow itself as his expe-
rience increases, if he start right in the beginning.

Although the heroic medication, which was so prevalent in the first quarter

1857.]

Forbes, Of Nature and Art in the Cure of Disease.

419

of this century, has of late years been to a great extent relinquished by a
large portion of the profession, there is still so much of undiscriminating and
incautious drugging, that there is great need of such efforts as Sir John Forbes
and others have put forth to arrest it. We hope that the subject of his book
will continue to be agitated. It is the great subject for the consideration of
the profession at the present time. "Whether our therapeutics shall come out
aright from its present transition state, depends upon the manner in which this
subject shall be investigated. If it be examined in the proper manner by
those who write upon it, and by practitioners as they go about in the daily
rounds of their practice, there will be greater advances in practical medicine
in the next twenty five years than have ever been made in the same length
of time before. We have said that the presentation of the subject by our
author, though. very full, is yet in some important points defective. Let
others, each in his own way, pursue the discussion, so that the subject may
be presented in every variety of phase, and it will then be fully developed,
all defects being supplied and all errors removed.

The great diminution of positive medication during the past twenty or
thirty years has been attributed, by some, in a great degree, to the influence
of homoeopathy. . As the reader has already seen, Sir John Forbes goes be-
yond all other physicians in this opinion. That the demonstration of the
capability of nature to cure disease, made by the followers of this infinitesimal
practice, has had some influence in bringing about the result referred to, we
most cheerfully allow. But its influence has been incidental and secondary.
Homoeopathy has merely aided a movement which originated from causes
existing in the profession — causes which had begun to operate long before
this system of quackery had obtained a foothold in the community. And it
was no part of Hahnemann's design to do the good which he has done to the
profession. He did it unwittingly. He had no belief in the curative power
of nature. It was medicine "dynamized" by trituration and a certain num-
ber of "downward shakes," by which, in his opinion, disease was to be cured.
He had not the remotest idea that the diffusion of his system was to aid the
profession which he affected to despise in carrying on a reform that had already
fairly begun. He did not discover that as his system should pass away, as all
other exclusive systems had done before it, it would leave, as a valuable re-
siduum, abundant evidence, in connection with that which medical men had
been themselves collecting, of the grand truth that nature is the chief curer
of disease. Though we can think of him only as an arrant impostor, we are
thankful, on account of the good service which he has done the cause of prac-
tical medicine, that he was permitted to live, notwithstanding the evil which
the temporary popularity of his system has occasioned.

There are many more points in the book of Sir John Forbes which it would
be interesting to notice. But it has not been our object to write a full review
of it, but to touch upon some points which particularly required our attention,
on account of their importance, or on account of some errors which we had
found in his treatment of them, leaving the reader to resort to the book itself
for a knowledge of all the author's views. And we would repeat the wish
that the book may be reprinted in this country and have an extensive circu-
lation. W. H.

420

Reviews.

[Oct.

Art. XV. — Cours Theorique et CHnique de Pathologic Interne, et de The-
rapie Medicale. Par Gr. Gintrac, Professeur de Clinique Interne, et
Directeur de l'Ecole de Medecine de Bordeaux, etc. etc. etc. Tomes 1, 2, 3.
Pp. 669, 696, 840. Paris, 1853.

A Theoretical and Clinical Course of Internal Pathology and Medical Thera-
peutics. By Gr. Gintrac, Professor of Internal Clinics, and Director of
the School of Medicine of Bordeaux, etc. etc. etc. Yolumes 1, 2, 3.

The three volumes before us are the commencement of a system of scientific
and practical medicine, which, if completed with the same ability as is evinced
in the preparation of these, cannot fail to rank among the most erudite, com-
prehensive and valuable that have heretofore appeared. It will form, in fact,
a comprehensive system of general as well as special pathology and thera-
peutics.

The work opens with a series of instructive preliminary remarks on the
nature of medicine ; its origin, first as an empirical art, and subsequently as a
science based upon determinate principles; with a general consideration of the
bases upon which it rests, the obstacles that impede, and those which have
favoured its progress. Embracing under the latter head a rapid sketch of
those who, by their labours, whether as observers or investigators of disease,
its nature, causes, phenomena, and treatment, as collectors and systematic
compilers of facts contributed by others, or as writers and teachers, have exer-
cised a powerful and permanent influence in promoting the onward march of
medical science and practice ; of the various institutions — schools, hospitals,
clinics, scientific associations, periodical publications, and museums of patho-
logical specimens, that have been productive of a like result; and, finally, of the
aids afforded in the improvement of the healing art by the progress of the
accessary sciences, anatomy, physiology, natural history, comparative patho-
logy, chemistry, physics, astronomy, and general philosophy.

This division of the introductory portion of the work terminates with a con-
sideration of the degree of certainty, utility, and dignity to which medicine,
as a science and an art, may rightfully lay claim.

The succeeding division is devoted to a sketch of bionomia, or a brief sum-
mary of the phenomena and laws of the organism of man in health, as an in-
troduction to the study of human pathology.

The generalities of pathology are then considered, comprising a general
idea of disease, its definition, causes, symptoms, progress, varieties, complica-
tions, terminations, seat, nature, semeiology, diagnosis and prognosis, including
a general notice of pathological anatomy, chemistry, microscopy, and phy-
siology.

The first volume concludes with a consideration of the generalities of thera-
peutics, under the heads of, 1. The different therapeutic methods — the ex-
pectant and active, the natural and perturbative, the rational and empirical,
the synthetic and analytic, the etiological and symptomatic. 2. The thera-
peutic indications and agents. 3. Plans of medication: 1 — the direct, ex-
citant, general, special* 2 — the direct, sedative, general, and special; 3 — in-
direct medication, excitant, and sedative ; 4 — specific medication.

The second volume commences with the study of diseases in general.
These M. Gintrac arranges in three grand divisions. In the first, he includes
congenital lesions — monstrosities. In the second, the lesions produced by

1857.] Gintrac, Internal Pathology and Medical Therapeutics. 421

mechanical, chemical, or poisonous agents ; and in the third, vital and or-
ganic lesions.

The consideration of the lesions included in each division is followed by a
general sketch of their respective therapeutic management.

The lesions of the third division are treated of under two heads — 1. Ele-
mentary affections, or morbid conditions : a. Principally dependent on the
abnormal mode of action of the solids : b. Consisting in alterations of the
fluids, and especially of the blood : c. Resulting from a general alteration of
the solids and fluids — diatheses — with their general treatment. 2. Determi-
nate diseases; divided into seven classes — 1. Congestions; 2. Inflammations;
3. Hemorrhages; 4. Fluxes, and alterations of the secretions: 5. Organic
lesions; 6. Neuroses; 7. Fevers.

"This arrangement/7 M. Gintrac remarks, " has been purposely adopted.
1 have desired to place in the first rank the local diseases, which may be re-
garded as simple and primitive, and terminate with those which are more gene-
ral and very often consecutive to the others. I have had a further motive in
placing fevers in the last rank. In the consideration of this class of diseases
I have been obliged to enter into descriptions and observations which in some
measure appertain to the domain of special pathology. The transition from
general anatomy to the latter, will thus be rendered more natural."

The 5th class, that of organic lesions, is divided into four 'orders : 1. Le-
sions which consist in a notable change in some one of the physical properties
of an organ, without modification of structure. 2. Lesions which consist in
a change of structure from the occurrence of abnormal interstitial formations.
3. Lesions produced by the formation of independent organisms — entozoa,
helminthia. 4. Lesions resulting from a local extinction of life — gangrene.

The class of fevers is not completed in the third volume.

The last portion of the present treatise, which M. Gintrac informs us will
be the most considerable, and the most essentially clinical, will embrace the
special lesions — in other words, those of the external seusitive apparatus, of
the encephalic and nervous, of the locomotive, of the vocal and respiratory, of
the circulatory, of the digestive, of the secretory, and of the genital appa-
ratus.

The plan laid down by M. Gintrac is a most extended and comprehensive
one, and arranged in a manner that strikes us as most skilful and rational,
facilitating the acquisition of the principles and practice of medicine by gra-
dually descending from the general to the special, from the simple to the
complex. We trust that the author may be spared to complete the entire
plan of his treatise in the same spirit in which it has so far been carried out.
That he is fully competent for the satisfactory fulfilment of the important
task he has assumed, the volumes before us bear ample testimony. Deeply
versed in the literature of his profession, and, consequently, familiar with the
vast fund of medical knowledge accumulated and perfected by the successive
labours of the industrious and talented physicians of almost every clime and
age, and prepared, by ample clinical experience, and habits of close and cau-
tious observation, acquired under the most favourable circumstances, to apply
this knowledge to the successful preparation of a course of scientific and prac-
tical pathology and therapeutics, we have no fear that the succeeding volumes
of the present treatise will not equal those we have had an opportunity to
examine.

In all his teachings M. Gintrac is clear, definite, and concise; entering, at
the same time, sufficiently into details to present a fair and full exposition of
the present state of medical knowledge in relation to every subject of which

422

Reviews.

[Oct.

he treats, and to impart precise and accurate ideas of every point of importance
in his exposition of disease and its management. He is evidently more de-
sirous of presenting well established facts and principles than of dealing in
subtile discussions, or of acquiring for himself the doubtful praise of ori-
ginality in his theoretical or practical views. Upon mere hypothetical ques-
tions, or those of doubtful profit, he never dwells, but coming direct to what
he believes to be legitimate doctrines, established upon well observed and care-
fully digested facts, whether in the domain of pathology or therapeutics, his
teachings have a character of simplicity, combined with force and truthful-
ness, that render them particularly adapted for the profitable instruction of
the advanced student of medicine, as well as attractive to the practitioner who
is desirous, on any particular point, to test or compare the result of his own
observations with that of preceding and contemporary authorities in the pro-
fession.

The prelections of M. Gintrac are, moreover, all of a positive character.
Even on questions as yet unsettled, or in relation to which different or even
opposite opinions are entertained by eminent members of the profession, each
claiming to be sustained by positive facts and direct observation, the diffi-
culties in the one case and the discordant views in the other, are so clearly
and concisely presented by him as to enable the reader to form a correct con-
ception of the first, and assist him in judging of the amount of probability in
favour of the correctness of one or other of the latter.

We do not pretend to say that the work of M. Gintrac is without fault.
"We should not, certainly, feel inclined to indorse all the views advanced in
it in relation tov pathology, nor every direction given by the author for the
treatment of disease. We should be, nevertheless, willing to give to it our
unqualified recommendation as a full and well arranged system of the princi-
ples and practice of medicine — presenting a very fair exposition of generally
received doctrines, recognized facts, and established plans of treatment.

We may remark that M. Gintrac is among the few continental writers who
are willing to give credit to the physicians of this country for the contributions
they have made to medical science and practice.

That our readers may be enabled to form some idea of the manner in which
M. Gintrac handles the several subjects included within the scope of the pre-
sent course of pathology and therapeutics, we translate the following sections
from the part devoted to the consideration of fevers. We have selected these,
not because of the particular excellence of the views set forth in them, but
because they refer to an important question, upon which medical writers of the
greatest eminence have widely differed; namely, that general idea of fever,
which shall at once convey a clear conception of the disease in its true patho-
logical acceptation, distinguishing it from all other affections with which it
may be associated or complicated. To the selection of these sections we were
prompted also by the difficulty of finding any others sufficiently short for our
purpose, and in which the subject treated of is presented with the same de-
gree of completeness.

The first selection is from the section devoted to a consideration of the
general idea of fever.

"Increased heat was, with the ancients, the principal sign — the essential
character of fever. There are, however, fevers in the course of which the tem-
perature of the body, far from being increased beyond the normal standard,
does not reach it, or even remains far below it. Such is the case in the fevers
denominated algid. In the first stage of intermittent fever also, there is a sen-
sation of cold. Often the temperature is so little changed that scarcely can the
hand of the physician discover any difference. In order, therefore, to form an

1857.] Gintrac, Internal Pathologij and Medical Therapeutics. 423

exact idea of fever, it is necessary to have recourse to some other charac-
teristic.

"According to Stahl, fever, considered abstractedly, consists in a modification
of the course of the blood, especially in an acceleration, and a certain abnormal
direction of the circulation. Boerhaave, in the same manner, indicates the fre-
quency of the pulse as the most constant phenomenon of fever; the one which
denotes its invasion, and which ceases only with it. Quesnay and Dehaen adopt
a similar definition. Piquer has remarked, and very justly, that, for the phy-
sician to detect the presence of fever, it is not necessary for him to be acquainted
with its essence or its mechanism. Embracing with his fingers the wrist of his
patient, and compressing lightly the radial artery, he thus perceives, at the
same time, the heat of the skin and the frequency of the pulse. He is at once
enlightened, and enabled to decide upon the presence or absence of fever.

" The physician would nevertheless be led into error, were he in every in-
stance in which, the pulse is accelerated and the skin hot to conclude that fever
is present. An individual may have experienced a violent mental emotion, or
some other powerful excitement; he may have partaken freely of stimulating
food, or of alcoholic drinks, which, particularly if he be young and of an ex-
citable temperament, would be sufficient to cause an acceleration of pulse, and
lead to the supposition that he was actually labouring under fever, when, in
fact, he had not passed from a physiological state. There are also organic
lesions of the heart that produce frequency and irregularity of pulse, without
the actual presence of fever ; in such cases, however, the presence of other
symptoms would reveal the existence of the serious lesion by which the dis-
turbance of the circulation is produced.

"With these and some other somewhat similar exceptions, to be noticed here-
after, frequency of pulse may be received as the most certain sign of fever.

" We are not, however, to suppose that an idea so precise and simple as this
has been generally adopted. Stoll says that in fever there is an alteration of
the pulse, and a lesion of one or several functions. The expression alteration
ie an extremely vague one. Selle is still more indefinite. According to him,
fever is a disease variable in its course and duration, and accompanied by heat,
cold, and a pulse sometimes more frequent, at others slower than during the
ordinary state of health. Afterwards, however, he is more precise, when he
pronounces fever to consist in variations of temperature, frequency of pulse,
spasm of the heart, and acceleration of the circulation of the blood.

"Grimaud objects to the definition of Boerhaave, because the determinate
character of fever laid down by the latter is often absent. Thus Galen, Sar-
cona, and Worlhoff describe fevers in which the pulse was slow. Grimaud,
however, distinguishes frequency of pulse — that is, the number of pulsations
in a given time — from celerity or quickness, which relates to each separate
pulsation, which may be completed in a variable period of time. Thus the
pulse in fever may be quick, but not frequent. Fordyce and Boisseau consider
it inaccurate to assume acceleration of pulse as the pathognomonic sign of fever,
inasmuch as it is observed in diseases that are non-febrile, and is sometimes
absent in genuine fevers.

"All this discrepancy of opinion results from the fact that certain morbid
conditions, certain groups of symptoms, have been classed with fevers, although
independent of them. Thus, hydrophobia is ranked with the fevers by Selle,
while it actually belongs to the neuroses. The acute ataxic condition has been
assimilated with the nervous fevers, although frequently unattended throughout
with fever. Certain apyretic periodical affections have been ranked with inter-
mittent fevers, under the denomination otfebres larvatce; it being supposed that
in these fever was actually present, but, at the same time, veiled or masked, so
as not to be detected exteriorly. Let us, however, aim at something more
definite. When the pulse is normal in respect to frequency, is there fever?
Do there exist fevers without fever? Is fever one of those mysterious beings
which are sometimes apparent, and at other times, though present, invisible ?
To have recourse to such a supposition, is to create the purest ontology. How
loudly would the partisans of the physiological and organic doctrines exclaim,
and very justly too, against it.

424

Reviews.

[Oct.

"Let us avoid, as far as possible, doubtful conceptions. The practitioner
has need of a precise formula, of a definition exact and well understood, of a
definition clear and recognizable. For him there is fever whenever the heat of
the skin is modified, and especially when it is augmented ; and when the pulse
is evidently more frequent than in the physiological condition. To these cha-
racteristics others are added, as thirst, spontaneous lassitude, etc.

"What do this acceleration of the pulse, and this increase of heat, which
constitute the characteristics of the febrile condition, denote ? With what
form of organic or functional lesion are they connected? They result, evi-
dently, from an augmentation of action in the heart and bloodvessels ; from
the disturbance and stimulation of the organs of the circulation. This has
been correctly remarked by many authors. According to Quesnay, fever con-
sists, radically, in the excess of action in the arteries. Stoll expresses himself
thus, in his seventh aphorism: 'The phenomena of fever are deducible from
the irritability of the heart and arteries, augmented and excited by some sti-
mulation/ Ludwig speaks in these terms: ' Circulatio sanguinis et Tiumorum
auctafebris dicitur. Febrium indoles et vis in circulo sanguinis cernitur.' We-
dekind, of Mayence, and his pupil, Herzig, define fever 'disease of the entire
System, resulting from an abnormal activity of the heart and bloodvessels, ex-
cited and maintained by an internal cause/ Benjamin Rush places its seat in
the bloodvessels, and defines it to be an anomalous action or a convulsion of
these vessels. Rolando refers its production to cardiac excitement.

" Thus, according to numerous observers, fever is an affection of the circu-
latory apparatus. It is the augmentation of action, the general excitation or
hypersthenia of the vascular element. To this idea, deduced from the closest
scrutiny of the phenomena of fever, there have been joined considerations of
a more recondite character. Thus, fever, or the excitation of the circulatory
apparatus, is viewed as a reaction provoked by some agent which disturbs the
vital harmony. It is, says Fages, the result of the reactive efforts of nature
against the impression of a morbific cause. According to the physicians of
the school of anamists and naturists it is for the purpose of purification that
fever establishes itself ; hence, they give, as its etymology, the Latin word
februare, to cleanse, to purify. The perspirations, the different evacuations by
which the accessions of fever are terminated have given an appearance of
truth to this opinion.

" The febrile reaction, with the conservative and critical efforts which it in-
duces, demonstrate, according to Stahl, the intelligence of nature, the auto-
cracy of the soul, while, in the opinion of M. Cayol, it constitutes even a func-
tion.

" After all, however, fever is in truth nothing more than a morbid condition.
However advantageous may be, in some instances, its results, it commences
invariably by a serious derangement of the organism, a general disturbance of
its functions. This perturbation has not always a beneficial end, a favourable
result. Too often it destroys the strength and exhausts completely, in fruitless
agitations, the resources of the organism."

The second section we shall translate is that which treats of the distinc-
tion of fever into essential and symptomatic.

"We conclude, then, from what precedes, that fever consists in a more or
less intense excitation of the circulatory apparatus. In all cases in which we
cannot discover any serious lesion in any organ beyond that apparatus, the
effective disease — that is, the fever — must be evidently essential or idiopathic.
If, on the contrary, we recognize in any part of the organism any lesion, under
the influence of which the fever has originated, we should then consider it as
symptomatic or secondary.

" This distinction, presented thus generally, appears clear and evident, but,
in its application, there occur some difficulties.

"Galen saw in fever, sometimes the result of an alteration of the humours,
sometimes the result of an inflammation. Baillou separated, distinctly, essen-
tial from symptomatic fevers. Guittierez discusses this question: ' Sit no acci-

1857.] Gintrae, Internal Pathology and Medical Therapeutics. 425

piendoz febris divisio in morbum et symptoma? and resolves it affirmatively, in
employing all the syllogistic formula so much in vogue during his time. Until
Pinel, little attention was paid to this distinction of fevers, which was regarded
as scholastic. Selle embraced in the class pyrexia the most part of the acute
phlegmasia, the exanthemata, many organic lesions, and even some of the neu-
roses. Our celebrated Nosographer, to avoid this confusion, banishes from the
domain of pyretologia all those diseases alien to it, and lays down the princi-
ple that essential or primitive fever may present itself under certain determi-
nate forms, and is subordinate to the organ principally affected. Rejecting the
idea of a simple fever, he refers inflammatory or agiotenic fever to the blood-
vessels ; bilious or meningo-gastric fever, to an affection of the stomach ; the
mucous or adeno-meningic, to the alimentary mucous membrane ; the adyna-
mic fever, to the muscular system ; the ataxic fever to the nervous system, and
the adeno-nervous, to the glands and the organs of innervation.

" The greater part of these denominations, and the various local seats of
fever indicated by them, led Pinel, without his intending to do so, to rank
fever not as an essential disease, but as a morbid condition dependent upon a
lesion of different parts of the organism. In following the principles adopted
by the author of the Nosographie philosophiqiie, we are led to a complete over-
throw of his doctrine. It was, in fact, early opposed. Cortambert opposed
the denomination of essential fever. Caffin rejected such fevers, and referred
them all to a local affection. Bravet followed, by an analysis of each special
order of fevers, and showing their particular localization. Parkinson goes
still further ; he would erase from nosology the very term fever, as never ex-
pressing anything beyond a symptom. Subsequently to the year 1804, Prost
had collected a great number of clinical and necroscopic observations, which
prove the direct relation of the different orders of fever, and especially of the
ataxic fevers, with divers phlegmasia. Hence, when Broussais came to aim the
final blow that was to overthrow the pyretological system of Pinel, the medical
mind was prepared for such revolution ; it nevertheless required an athlete
like the professor of Val-de-Grace to triumph over a doctrine which had been
looked upon as invulnerable. But, it is not alone the partisans of Broussais
who have opposed the essential character of fever. Fages, a learned disciple
of the school of Montpellier, rejected the idea of a simple, essential fever. He
denied that character to the fevers denominated inflammatory, bilious, and
mucous, because that the ' inflammatory bilious, and mucous conditions may
exist without fever. According to him, fever is merely a symptom, a reaction,
and cannot, therefore, form the distinctive character of a class of diseases.
In our day, similar opinions are professed by the celebrated Schoenlien, of
Berlin. He sees in fever, nothing but a reaction — the participation of the eco-
nomy in the disorder of an organ. It is not the disease, but only its shadow.

" This opinion is certainly an exaggeration. Fever constitutes often that
which is the most essential or the most important in a disease. This must be
admitted when, upon the most rigorous analysis, no actual disturbance can be
discovered excepting in the circulatory apparatus; when this trouble is due to
general influences, which have modified the entire organism without producing
any local lesion ; finally, when, on opening the body after death, we discover
no trace of an alteration capable of explaining the fatal termination of the
case, of which Chomel has furnished examples.

" Foquier and Lerminier, reporting to the Society of the Faculty of Paris, on
a memoir presented, on this important subject, by M. Chomel, endeavour to
determine in what the essentiality of fever consists. I quote their words,
which appear to me to express views that are perfectly just.

" ' The alteration of the animal heat and of the circulation is the result of an
irritation experienced by the vascular system. Whether this irritation is con-
fined solely to that system, or takes its source in all parts of the body, it will
not be less essential, so long as it is not produced or kept up by an anterior or
concomitant affection alien to the vascular system.' These skilful practitioners
add this reflection : ' If loss of appetite, some pain of the epigastrium, and a
slight redness of the tongue suffice to indicate the presence of gastro-enteritis,
redness of the face, a sense of weight in the head, and cephalalgia, should, in

426

Reviews.

[Oct.

like manner, lead us to infer an inflammation of the brain or its meninges ; and
yet all these symptoms may quickly disappear, and, in every case, much more
readily than would be the case were they dependent upon actual inflam-
mation/

" But fever often accompanies various local lesions — are in such cases the
latter to be viewed as causes or effects?

" M. Camille Leroy has remarked, 1st, that the general phenomena most
often are the first observed, while the local affection does not manifest itself
until subsequently. 2d. That the causes act upon the entire nervous system,
the whole circulatory apparatus ; that they make their first impression upon
the organic centres, upon the very sources of life, and do not give rise, but
subsequently, to congestions and fluxions, which are the consequences, and not
the motors of the febrile movement. I fear that by this mode of reasoning we
shall be led too far. Do we not every day see pneumonia, or some other
serious and incontestable inflammation preceded by prodroma and intense
fever? The local phenomena do not present themselves with energy until at
the end of some days. Should we, therefore, regard the local inflammation as
the consequence of the febrile movement ? It is from such a view of the sub-
ject that the acute exanthemata have been brought back among the essential
fevers, and in this I believe that vce have ma.de a retrograde step.

"To avoid all confusion, we shall consider as essential fevers such only as
present beyond the circulatory apparatus, phenomena that are of little im-
port, variable, mobile, and of themselves incapable of exciting a reaction ; but
we shall refuse the title of essential to a fever from the period when there
occur specific lesions, which exercise an incontestable influence upon the march
of the disease. Should the fever, even when it originates in a determinate and
perfectly recognizable local cause, be considered as a symptom of little value ?
Xo practitioner will reply in the affirmative. Take, for example, the most sim-
ple case, that of a wound, or of a fracture, by which fever may be excited, does
this latter, when it occurs, merit no attention ? Does it not become, by its in-
tensity or its particular progress, an important basis of indication ? When
convulsions or tetanus occur as the result of a traumatic injury, are these for-
midable accidents, because produced by a local cause, to be overlooked, ne-
glected as mere secondary phenomena ? If in a case of tetanus or convulsions,
the nervous system is disturbed, may not the circulatory apparatus be excited
when fever is produced. Does not the one morbid condition demand attention
equally with the other ?

"From the various considerations that have been presented, I believe the
following conclusions are to be deduced : —

"1. That the distinction of fevers into essential and symptomatic, at every
period, heretofore admitted, should be retained.

"2. That the domain of the essential fevers has been too much extended, but
that it would also be wrong to restrict it within too narrow limits, or to efface
it from the nosological chart.

" 3. That its true limits should be determined by observation.

" 4. That the fever which presents itself only as a symptom, should, under
certain circumstances, be taken into consideration as an indication of the active
part taken by the circulatory apparatus in the local disease.

" Desirous of simplifying the subject in question, I shall avoid as much as
possible in the succeeding consideration of fevers, all that relates to symp-
tomatic fevers. The latter present, in effect, independently of the phenomena
strictly febrile, those which appertain to the local affection of which it is the
coincidence or effect. Hence, in respect to them, it is easy for a confusion
to arise that shall impede the precise determination of the proper causes and
attributes of fever properly speaking. The essential fevers should be studied
apart from all others, for they may exist alone, as can easily be proved. They
may, also, co-exist with other diseases of which they are independent, but
upon which they exert an influence. A fever may, also, survive the local lesion
that has given it birth, and take then the character of an essential disease."

D. F. C.

1857.]

Wilson, Diseases of the Skin.

427

Art. XVI. — Diseases of the Skin. By Erasmus Wilson, F. R. S. Fourth
American, from the fourth and enlarged London edition. Philadelphia:
Blanch ard & Lea, 1857.

The writings of Wilson, upon diseases of the skin, are by far the most
scientific and practical that have ever been presented to the medical world on
this subject. For many years a large portion of his time has been spent in
the field of dermatology. His eminent position as a medical man in the me-
tropolis of England has afforded him the most ample scope for prosecuting
any investigations relating to the manifold abnormal conditions which the
external investment of the human frame is known to exhibit. The results
of these investigations he has proffered to the profession, by whom, without
doubt, they will continue to be appreciated on both sides of the Atlantic.
Mr. Wilson's style is in the highest sense elegant and classical ; it is abso-
lutely faultless. It possesses an individuality; it glows with a freshness and
flows from a depth of thought which mark it as emanating from the rich
fountain of his own brain.

The present edition is a great improvement on all its predecessors. In it
the indefatigable author has arranged, in part, a new system of classification,
founded, as he believes, on the only true basis, the cause of the disease. To
the consideration and elucidation of this subject one entire chapter is devoted.
A new chapter is introduced relating to the general pathology of cutaneous
maladies ; and another, in which their general therapeutics are discussed in a
very lucid and able manner. Moreover, we have a separate chapter on dis-
eases of the sebiparous glands; and a brief but valuable article on the malig-
nant pustule of the skin. The different syphilitic eruptions also occupy a
prominent position in the work ; and are arranged according to their forms
and the period of their development in a table of classification.

Probably no branch of medical education at the present day is so sadly
neglected, we might say ignored, as that which relates to a knowledge of the
skin ) and probably no department of medical and surgical practice is per-
formed in so blind, so graceless, so culpable a style as that bestowed upon its
maladies. Students look at the skin. Of course they do. They see that,
like the clouds suspended over their heads, it presents various shades of colour
between white and black. But, of its structural character, its anatomical
elements, and of its deviations from health, they are well-nigh as ignorant
as the untutored wild men of the forest. This, at least, is true of a vast
number, who seek refuge and patronage under the prestige and shadow
of a diploma, obtained at the fountains of medical science, that send their
streams through the length and breadth of the land. Well, this destitution,
or meagreness of knowledge, and its manifold direful consequences, accruing
to thousands who apply for deliverance from some annoying cutaneous affec-
tion, may be effectually removed through the instrumentality of the brilliant,
scientific light, reflected from the elegant pages of Erasmus Wilson. To one
inclined to ponder upon the suggestive and instructive contents of these pages,
with an attitude of mind open to drink in knowledge, it would seem as if the
spirit of philanthropy, united with the genius of sound learning, and com-
miserating the sufferings of humanity, had prompted and qualified our author
to present to his professional brethren a system — a code- — a practical guide,
at a most opportune epoch ; and which, if they follow, will be to them what
the skilful and faithful pilot is to a sea-tossed vessel, seeking anchorage in
a strange harbor.

428

Reviews.

[Oct.

To dwell upon all the great merits and high claims of the work before us,
seriatim, would indeed be an agreeable service ; it would be a mental homage
which we could freely offer, but we should thus occupy an undue amount of
space in this Journal. We will, however, look at some of the more salient
points with which it abounds, and which make it incomparably superior in
excellence to all other treatises on the subject of dermatology.

The first chapter of the book is dedicated to a consideration of the minute
anatomy and physiology of the skin. An exact description, couched in plain
but graphic phraseology, is given of the several component tissues, which, in
their united and associated capacity, constitute this most complex covering to
the entire human organization. The mind of the reader is thus, in the very
beginning of his study, placed upon a scientific basis, without which no real
useful improvement can be made in the practical department to which he is
subsequently introduced, and in which he expects to labour. To reach this
latter goal, through the medium of successful study, is a noble employment
for every medical student and for every practitioner of the healing art, and is
sure to carry with it its own most welcome reward.

In pursuing his investigations of the normal structural anatomy of the
skin, under the guiding hand of Wilson, the reader is agreeably surprised to
find that the patient researches and observations of his teacher have shed a
flood of light upon many obscure points that had obstructed his path in all
previous investigations ; and this light, this veritable knowledge which he has
gained in regard to healthy cutaneous structure, is easily and directly appli-
cable to the morbid anatomy or pathology of the skin ; in other words, to the
diseases that invade this tegumentary organ. For instance, Wilson has de-
voted much study to the mode of development and growth of the epidermis ;
and the curious results at which he has arrived, and which we can verify from
our own investigations, are detailed in the work before us. They are ex-
tremely interesting, and materially aid us in understanding some of the ana-
tomical features of lepra. The investigations we are now considering have
educed the fact that in this complaint the primitive epidermic granules are
abnormally formed, being in a state of hypertrophy from deranged nutrition
of the derma.

The structure of the hair has received a due share of attention, and conclu-
sions naturally flowing from these investigations are also presented for our
consideration. The minute organization of the pilous tissue harmonizes with
that of its analogue, the epiderma, being composed of the same primitive
granules, differing only in their arrangement, as being destined to serve a dif-
ferent purpose. These horny appendages of the skin, that is the hairs, are
produced by the involution and subsequent evolution of the epidermis ; the
involution constituting the sheath of the follicle, in which the hair is inclosed,
and the evolution the body or shaft of the hair. Our author condescends
even to the work of splitting of a hair; that is, his microscopical examina-
tions lead to a natural division of a hair into a central portion, a peripheral
extremity, the point; and a central extremity, the bulb or root. The coarsest
hair is found in the female, and the finest in the male. This is the reverse
from the general opinion. The habit of cutting the hair or shaving it, does
not increase its size. The hair is composed of three different tissues — a loose,
cellular tissue, which occupies its centre, and constitutes its medulla or pith ;
a fibrous tissue, which incloses the preceding and forms the chief bulk of the
human hair; and of a thin layer of superimposed scales, which envelops the
fibrous structure, and forms the external structure. The primitive granules
of the hair are arranged in such regular order as to have the appearance of
parallel fibres, and their variation in tint gives rise to diversity of colour in

1857.]

Wilson, Diseases of the Shin.

429

the hair. Under the influence of disease the hair is liable to a change, which
Mr. Wilson compares to the alteration of the epidermis which takes place in
lepra — that is, it becomes lax in texture, brittle, twisted, and is robbed of its
natural colour. The malady, of which we are told this morbid change is a
symptom, is " ringworm." An examination of the hair in this troublesome
complaint exhibits its primitive granules morbidly enlarged, like those of the
epidermic cells in lepra ; both diseases being a granular degeneration of the
cells of which the epidermal product is composed.

Another important and interesting discovery to which our author's investi-
gations have conducted is, that the pigment of the choroid membrane of the
eyeball and melanosis are composed of the same identical organisms.

Such are some of the examples of the first results of the application of
scientific research to practical uses. Wilson, in the plenitude of his modesty,
regards them as humble examples, but at the same time they offer induce-
ments for other similar researches.

The plates, illustrating the work, are fifteen in number, eight being co-
loured after nature, the remainder being plain. Each of the coloured plates
represents a group of diseases, and they will serve to assist the physician in
forming a diagnosis of any given specimen he may encounter on the living
subject.

The second chapter is devoted to a Classification of diseases of the skin.
By those who are familiar with the previous editions of Wilson, it will be re-
membered that the nomenclature which he adopted went by the title of the
" Natural System" founded on the physiology and pathology of the skin;
and took, as its leading features, the phenomena that wait on inflammation of
the derma, as congestion, effusion, suppuration, desquamation, &c. In all
essential particulars this arrangement coincided with the system of Willan.
To regard diseases of the skin merely as essential affections, located in some
one or more of the different component parts of the derma, while the others
are supposed to be in health, is doubtless correct reasoning in many cases;
but the theory is a hazardous one, and often a false one ; and the attempt
made by Wilson to remodel the system of Willan, and partially set up and
build upon it the anatomical or " Natural System," was regarded by many
as unsuccessful and fallacious. With this system our author himself was
dissatisfied, and for many years his mind has been engaged in constructing a
classification of a more practical and philosophical character. He has at last
completed an Etiological Si/stem of arrangement, which was initiated by
Hippocrates, and followed by Franck, Plumbe, Baumes, and others. The
advantages set forth as appertaining to this system, and raising it above all
others in the scale of excellence, are, that it renders the treatment of cuta-
neous maladies more simple and rational, and removes them from the special
and isolated position which they now occupy, into the general category of dis-
eases incident to the human frame. In some respects the present nomencla-
ture of Wilson reminds one of the views entertained by M. Devergie, of
Paris, who regards the determination of the precise dermic anatomical charac-
ters and seat of each particular disease as a matter of minor consequence, but
looks at the pathological relations of cutaneous maladies with the conditions
of internal organs, and of the system in general, as a matter of great import-
ance, and to be always borne in mind. He divides ail skin diseases into
secreting and non-secreting — a striking and practical mark as far as it goes.

The cardinal principles laid down in the present edition of Wilson in the
nosological arrangement and for the treatment of cutaneous disorders, leave
little room to complain of the hollow jargon and bluster of high sounding
words as applied to this branch of medical science. Nor will there any

430

Reviews.

[Oct.

longer be a reason for the neglect of their study on the part of the young man
who is preparing himself for the practical service of the physician and sur-
geon, either in his own consulting room, or at the bedside of the patient. Nor
need the limber tongue of the professor, who should be regarded as a reliable
oracle in the department in which he instructs, again be heard to designate as
tinea capitis a case of impetigo, which happens to be located on the face,
and which is on exhibition before a medical class. This blunder, incredible
and reprehensible as it may seem, we know to have been made not five years
ago, in one of our high courts of medical erudition and science, without a
blush or without correction from the gentleman who committed it. As we
speak no names, either of parties or of places, we allude to the fact without
apology. We have to remark, in this connection, that had the profession
been on terms of greater intimacy with Wilson, such a diagnosis would not
have been palmed off upon scores of young students, a portion of whom were
unable to reconcile what they heard with what they saw. Such ignorance,
at the present day, is without excuse, although in the early dawn of medical
knowledge it might have been winked at. The great work of Wilson will be an
important help, a reliable text-book for all students and professors and practi-
tioners, by whom it can be profitably consulted in doubtful emergencies, both
in the diagnosis and treatment of individual cases. We have heard Wilson
denounced by men holding a high position in the medical ranks, as being an
obscure writer, using language which they could not comprehend. These ob-
jections, however, have uniformly been of that class of practitioners who are
totally unfamiliar with the first elements of Dermatology; and who, although
excellent in the ordinary calling of physician or surgeon, find themselves in a
thick wilderness whenever cutaneous pathology or cutaneous therapeutics is
the theme of conversation. To be thoroughly understood, Wilson needs to
be studied with the same thoughtful attention and concentration of the mind
required for a proper comprehension of Homer or Horace in the ancient
classics, Lord Coke or Chancellor Kent in the law, Yelpeau in surgery, or
Mason Good in the general science of medicine.

The derma and its related dependencies, its multitudinous glands, and their
follicles or tubes — all highly complex in organization, and performing a di-
versity of functions essential to the well-being of the total physical economy,
are subject to various abnormal conditions resulting from inflammation.
These conditions admit of being divided into two primary groups, namely —
I. Diseases affecting the general structure ; and,

II. Diseases affecting the special structure of the skin.

Under the first primary group of diseases affecting the general structure,
the Etiological system of *Wilson embraces seven typical forms, five of which
correspond with as many orders of the Willanean classification, namely, Exan-
themata, Papulae, Vesiculae, Pustulse, and Bullae. These our author regards
as arising from general causes. The term general, as employed in this con-
nection, is intended to suggest the idea of a cause originating in the mal-per-
formance of the ordinary functions of animal life, rather than to include a
variety of causes. Wilson holds to the opinion, that all the diseases included
under this head proceed from one primary and essential cause — that is, mal-
assimilation; in other words, from an irritant poison generated in the organism
of the individual as a consequence of mal-assimilation — the morbid action
in the cutaneous tissues being a vital process, having for its object the elimi-
nation of that poison by the skin. It has been a dominant notion with many
practitioners of sound sense, that in diseases of the skin there is present in
the system some peccant element, which displays its malign influence upon
the cutaneous surface in preference to seizing upon other organs, for the rea-

1857.] Wilson, Diseases of the Skin. 431

son that nature instinctively employs this organ as the medium through which
she essays to rid herself of this inimical principle, whatever the principle may
be; and in performing this work, certain abnormal processes are brought into
play. The idea of Wilson is but a clearer, more definite, and more scientific
embodiment and expression of this notion. It savours largely of the old
humoral pathology of Brown, for so many years regarded as obsolete and
with disfavour — as a sort of fossil relic handed down from the dark ages of
medicine. But, after all the vicissitudes and fortunes which it has encoun-
tered, this same Brunonian pathology is once more considered to have its
foundation on the rock of truth, and not in the crude speculations of the
cloister, or in the blind credulity of ignorance. And the medical profession,
as well as those who may hereafter require their services for the amelioration
or cure of cutaneous disorders, will owe to Wilson a debt of gratitude for the
lucid manner in which he has presented this branch of his profound and diffi-
cult labours ; for these labours will conduct to the most auspicious results in
the field of therapeutics.

Admitting that mal-assimilation is the great primary cause of diseases
affecting the general structure of the skin, the variety which is presented in
the form and condition of the apparent disease, is simply the product of cer-
tain phenomena that are known to modify the features of disease when any
Other organs of the system chance to be the seat of that disease; the result,
in fact, of predisposing causes, either congenital or acquired.

Diseases arising from general causes are divided and grouped in the follow-
ing manner : —

a. Erythema (exanthemata). c. Eczema (vesiculas).
Pityriasis. Psoriasis.
Erysipelas. Sudamina.
Roseola. d. Impetigo (pustulae).
Urticaria. Ecthyma.

b. Lichen (papulae). e. Herpes (bullae).
Rosacea. Pemphigus.
Strophulus, f. Furunculus,
Prurigo. Anthrax.

g. Purpura.

To those who are accustomed to the study of cutaneous pathology, accord-
ing to the nomenclature of Willan, or according to the previous editions of
Wilson, it may seem not a little odd, that psoriasis should be transferred from
the position it has so long held among the squamae, to be introduced into the
order vesiculae. We confess we should as soon thought of looking for a
tropical plant in the frigid zone ; or we should as soon have expected to find
erythema transplanted from the prominent position where it now stands- as
the representative and type of the exanthemata, to be arranged with the order
papulse or tuberculata. Perhaps time and further study may prepare and
accommodate our mind for the unexpected change — a change to which we are
not now reconciled. We have already signified our high respect for the eru-
dition of Wilson ; and were it our custom to yield in blind acquiescence to
any writer on the subject of dermatology, Wilson would be that man.

In chronic cases of psoriasis, or psoriasis inveterata, a trifling, serous exu-
dation, of entirely insignificant import, is occasionally seen in the fissures
produced in consequence of the long existing hypertrophy and low degree of
inflammation ; but a retrospection of the eruption conducts back to a small,
hard, red papule, which, after an existence of two or three days, has its sum-
mit surmounted and whitened with a minute scale; and if its initiatory
pathological change is suggestive of any change in name, it would be, in our
opinion, that instead of a squama, psoriasis might, with some seeming pro-

432

Reviews.

[Oct.

priety, receive the cognomen of papule, and be affianced in the same order
with lichen. But when we find psoriasis coupled in the same order with
eczema — a disease characterized from the very outset by the formation of
almost innumerable vesicles — colourless and transparent globules, we confess
our inability to harmonize the elements of the latter affection, with those
small, solid, scaly elevations, which announce the disease to be psoriasis.
Whatever changes or varying products may characterize either of the dis-
orders here alluded to, during their more advanced periods, no alteration in
the generic name, suggested by the typical form of these maladies, would be
called for in consequence of these ulterior changes. Time operates great
transformations in diseases as well as in other matters — in men — in trees —
in flowers — in rocks. Take, for instance eczema. To day, it may be purely
a vesicular eruption. To morrow the vesicles will have risen perhaps to im-
perfect pustules; and the diseased patch will yield a sero-purulent discharge,
and will present other features, which will bring it into near alliance with
impetigo. Nothing, in fact, is more common, than some such modification
of the original, typical form which the eruption presented. Where such
transformation takes place, the dermatologist adds a qualifying term. In
the instance supposed, the name eczema receives the appendix impetiginodes.
This covers the whole ground. The nosologist and pathologist are both
satisfied and agreed. Thus in psoriasis : If a case happens, during the
existence of which a slight and occasional ichorous exudation constitutes
one of its features, perhaps the term eczematous psoriasis might be admis-
sible ; although it is extremely doubtful if the vesicles of eczema are ever
detected in psoriasis. We have examined hundreds of cases of the latter
complaint, and in none did we ever discover a vesicle, such as presents itself
in eczema, or anything akin to it. And we would ask, who has? In regard to
eczema, it may be remarked, that however chronic it may be, it never loses its
tendency ever and anon to develop vesicles. These vesicles, in aged or very
feeble subjects, sometimes part with their watery contents by the process of
absorption; and the cuticular capsules remain unbroken for a considerable
time ; are a mere scale, covering the derma ; and to the unpracticed eye bear
a strong resemblance to psoriasis. And we have seen in individual cases,
where a brief contest seemed to have sprung up between the two maladies
now in question — the one apparently straggling to supplant the other; but
being of such opposite elementary attributes, and endowed with such different
natural tendencies — the one to generate the vesicles, and the other not, we
are never at a loss to draw the line of demarcation.

In his seventh chapter, and in connection with what is offered relative to
eczematous eruptions, Mr. Wilson has the following explanation in reference
to the removal of psoriasis to the position it now holds among the vesieulse : —

"In the present group of cutaneous affections, the eczematous group, I have
thought it right to restore to its proper place the term derived from the He-
brew, tsorat, namely, psoriasis, which, as Mason (food observes, 'having lost
its primitive and restricted signification, seems to have wandered in search of a
meaning, and had at different times, and by different persons, various mean-
ings attributed to it; being sometimes used to express scaly eruptions gene-
rally, sometimes the scales of leprosy; but last, and with a pretty common
consent, the far highei efflorescence of scaly tetters or scalls, denominated in
the Levitical code, saphat ; and by the Latins, scabies, or impetigo sicca.' Pso-
riasis, in its proper acceptation, signifies a scaliness of the skin, resulting from
chronic erythema, attended with thickening of the tissues of the derma, and
more or less chapping of the inflamed part ; in a word, chronic eczema, when
eczema has produced a thickened and chapped state of the skin, and ceasing
to pour out an ichorous secretion, throws off from the inflamed surface a sue-

1857.]

Wilson, Diseases of the Skin.

433

cession of scales ; or chronic lichen agrius, when lichen has left a similar con-
dition of the skin, the papules of the original eruption being obliterated in the
general thickening of the chronically inflamed part. In truth, psoriasis is to
eczema and lichen agrius, what pityriasis is to erythema.

" It will be seen by these observations, that I might have introduced psoria-
sis into the group of lichenous eruptions, following lichen agrius ; but I have
preferred to attach it to eczema, because, in truth, lichen agrius and eczema,
as being in part a lichen passing into the stage of eczema, or assuming the
characters of eczema, of being indeed a lichen eczematosus."

The second sub-group or division, embraces those diseases which arise from
special external causes — such as parasites in or under the skin ; and those
diseases which are produced by the destructive agency of heat and cold. Of
the maladies affecting the general structure of the skin, it is in this group
alone that we meet with affections of the cutaneous surface, independent of
constitutional origin ; — those of other groups being essentially blood-diseases,
and arising from a morbid condition of that fluid.

The third group, which is an important one, includes diseases arising from
special internal causes. The number of these diseases is five — lepra, a
squama; and lupus, scrofuloderma, kelis, elephantiasis, the last four being
of the order tuberculata of Willan. In this group the cause is unknown, or
merely hypothetical.

The fourth group relates to diseases arising from the syphilitic poison.
This cause is well known and universally recognized.

The fifth and last group, embraces those diseases which arise from animal
poisons of unknown origin, and give rise to eruptive fevers. The individual
diseases proceeding from these poisons are, rubeola, scarlatina, variola, varicella,
vaccinia. All the foregoing groups affect the general structure of the skin ;
and constitute Wilson's first great division. The etiological method of classi-
fication is confined to this category of maladies, which, with the exception of
the second sub-group, have their source in constitutional disturbance — in
some abnormal state of the vital fluid.

The second grand primary division comprises those affections which have
their seat in the special structures of the skin; that is, in its vessels and
nerves; in its papillae; in the pigmentary principle; in its glands, hair, and
nails. Wilson regards these constituents and appendages of the skin as so
many heads, under which the morbid affections may be considered. A small
number of these diseases are constitutional; but most of them are simply
local — pure diseases of the skin, and removed from the influence of the con-
stitutional powers; and therefore the application of the etiological nomencla-
ture would not be attended with any advantage over the old physiological
system; and to the latter our author adheres in the classification of this
second great division.

At the end of the chapter, which is devoted to a consideration of the sub-
ject of classifying the various disordered conditions of the skin, a tabular view
is presented, and is divided into two parts, corresponding with, and naturally
growing out of, the previous text. That is, the names of the individual dis-
eases affecting the general structure of the skin, are placed before the reader,
by themselves; — and lastly, the diseases affecting the special structures of the
skin, are named and arranged by themselves; — the particular anatomical
constituents of the skin, in which these local maladies exist, are also specified.
Thus, the student is furnished with every possible help which he can reason-
ably desire, or which the nature of the subject renders practicable.

The observations relating to the general pathology of the skin are highly
interesting and important. The clear and logical manner in which the sub-
No. LXVIII.— Oct. 1857. 29

434

Reviews.

[Oct.

ject is presented, is entirely satisfactory, and is eminently calculated to instruct.
It is impracticable, in this connection, and in justice to the author, to offer
an epitome of what he has written with so much care and good sense, with
a view to show the analogy between different diseases of the skin. We
choose to commend the entire chapter to the careful attention of all who are
either practically or theoretically interested in the subject of Dermatology.
While it is with unfeigned pleasure that we speak thus of the great merits of
this chapter, we feel justified in saying that it contains a remark in regard to
Lichen, which is at variance with our own observations ; and we doubt not
but Mr. Wilson will listen candidly to the few words we take occasion to
submit upon the point we refer to. We are told that

" The papules of lichen are never found upon the scalp, the palms of the
hands, or soles of the feet; in the former situation, probably because the pores
are large, more firmly retained in their place from their relations to hairs, and
the skin between the pores more susceptible of congestive action. In the latter
they do not occur in consequence of the thickness of the cuticle/'

A few years since a boy, eight years old, was under our care for a chronic
lichen, which had been upon him for more than two years. The papules
were disseminated over large districts of integument covering the body, limbs,
face, and scalp. While we had charge of the case it was seen by several
medical friends. Within the past year, a woman forty years of age, of thin,
spare habit — a great sufferer from dyspepsia — consulted us for a papular
eruption on the hands and lower part of the forearms. The palmar and dorsal
aspects were about equally occupied by the eruption, which was a well de-
veloped lichen. It lasted about four months before it wholly disappeared.

The lad above mentioned was cured during a voyage to the Sandwich
Islands, the place of his birth. In the case of the woman, all the fingers
and both thumbs were more or less involved in the eruption, as well upon
the inner as outer surface. The two instances here cited go to show that
one man, although occupying a favourable position for observation, may not
see everything that appertains to the most common diseases, whether super-
ficial or otherwise.

The general therapeutics of the skin constitute a very essential and promi-
nent feature of the volume before us. They are considered in relation to
cutaneous diseases that are acute and chronic : in reference to the three periods
of life, infancy, manhood, and old age; in respect to different temperaments,
normal and abnormal; in persons of different idiosyncrasy and diathesis;
and in different conditions of vigor or debility of the system. The local and
constitutional methods of treating cutaneous affections, in all their various
stages, whether of an acute or chronic form, are thoroughly discussed ; and
the value of each method is presented to our consideration. The two branches
of the subject, that is, the medical and surgical, are harmoniously blended
together in a manner that will best secure that mutual aid, which is so im-
portant and efficient in carrying out a scientific and successful management
of these diseases. A union of the qualities of a well educated physician and
surgeon is required. The services of neither can be discarded or dispensed
with. The etiological principle of classification, adopted so far as relates to
those diseases that are believed to have their origin in an unhealthy condition
of the blood, naturally suggests and develops this view of the mutual ad-
vantages and importance of having the surgical and medical features of the
treatment nicely balanced. The mere local disease — the eruption of the skin,
is but a symptom, an index of the disorder of the blood. To one familiar
with the cutaneous eruption that may be present in any individual case, the

1857.]

Wilson, Diseases of the Skin.

435

cause of the constitutional aberration will be apparent. The external symp-
tom reveals the diathesis of the patient, and gives a clue to his medical
history; and to the intelligent mind of the practitioner, who understands the
cardinal principles of surgery as well as those of the medical art, this same
abnormal state of the skin — this local symptom spread out for visual inspec-
tion, will be suggestive of a proper line of conduct in attempting to remove
the constitutional disorder, as well as that which is displayed upon the skin.

Diseases of the skin, issuing from mal-assimilation, are rarely benefited,
our author tells us, by depletion either with the lancet or leeches. This doc-
trine is worthy of all acceptation. Years ago this was our creed ; we can
hardly say from whence we received it ; but we have long practised upon it.
The best remedies, even in the acute stage, are moderate purgativss, efferves-
cent salines, diaphoretics and diuretics ; and when the acute stage has passed,
Wilson advises tonics, bitters with mineral acids, or with alkalies — with or
without the ferruginous salts, according to the hsemic or anaemic condition of
the patient.

In chronic affections of the skin, the presence and the effects of mal-assimi-
lation are more or less obvious; and are evinced by various symptoms, inde-
pendent of any cutaneous derangement. A careful examination will bring
these symptoms to light. Although the patient may consider that he is in
fair health, it will be found that the functions of digestion are badly performed.
There is mal-conversion, mal-appropriation of the food taken to support the
system ; there is imperfect chyme and imperfect chyle, and of course impure
blood ; and the organs, which it supplies, are injured in their physical con-
dition, and impaired in their functional powers. The muscular apparatus is
enfeebled — the heart palpitates; the brain and nervous organization suffer —
the intellect is depressed, and other mental derangements ensue. Dyspepsia
may be a trifling affair in itself, and mal-assimilation a small matter when
considered apart, but Wilson regards these conditions as the authors of various
cutaneous maladies ; and when thus viewed in relation to their consequences,
they may very properly be ranked among the most serious of the bodily
infirmities of man. The current of impure blood goes into the minutest
tissue and into the most attenuated ramifications of that tissue, throughout
the corporeal frame. The lungs, the liver, the kidneys, the skin, are all
irrigated and enfeebled by this poisonous stream. The whole system be-
comes loaded with morbid humours of greater or less intensity; and the
skin, as one of the emunctory channels, is called upon to eliminate the
disturbing agent, while the other emunctories may be left to perform their
normal service The enemy is driven to the surface, causing congestion ;
and the extra labour of the cutaneous vessels commences. The result is,
that the patient may have an eruption of erythema, a lichen or eczema. Here
we have an illustrative example of the humoral pathology and the faith of
our author in its reality explicitly announced. He holds and inculcates the
same views in relation to diseases more profoundly located.

"What," he asks, " determines the seatof the congestion ? To which the answer
is plain — Temperature, season, age, idiosyncrasy, previous debility or disease,
the predisposing or exciting cause. In the cold seasons of the year, the morbid
humours, driven, for elimination, upon the mucous membranes of the lungs,
may occasion bronchitis ; in warm weather they may be precipitated on the
mucous membrane of the alimentary canal, causing diarrhoea; under the in-
fluence of moral excitement, the result may be apoplexy ; or, in other states of
the system, gout, rheumatism, or neuralgia. Or, in the absence of, or even in
association with any of these, the seat of elimination may be the skin, &c."

It has already been remarked that the methods of treatment, as relates

436

Reviews.

[Oct.

both to acute and chronic cutaneous disorders, are in conformity with the
pathological ideas, which are so eloquently urged upon the practitioner.

If the symptoms assume an acute, inflammatory type, the febrile excite-
ment is to be reduced, and an attempt must be made to neutralize and elimi-
nate the morbid properties of the blood. In chronic diseases all this must
be done, while at the same time the constitution must be buoyed up, by
resorting to a tonic course of remedial measures. In some patients a depres-
sion of the vital energies is produced by a mere accumulation of morbid
humours, in which case, our author argues, simple elimination by purgatives
will strengthen the whole frame, and will heighten, rather than diminish, the
power of the patient. Such cases, however, are rare, compared with those
which, from the beginning, require a tonic system of treatment, rather than
cathartics.

When a patient, suffering from chronic cutaneous disease, presents himself
for medical advice, the practitioner should set himself to inquire into the
particulars of the case, and then propound to himself : what are the indica-
tions to be fulfilled? They are, firstly, to eliminate; secondly, to restore
power ; thirdly, to alleviate the local distress. These three indications are
considered in detail, together with the means at the command of the medical
adviser, for fulfilling them. This portion of the volume supplies much
valuable instruction, not met with in any other work ; and it will be found
of great utility in the diffusion of sound philosophical principles, relating to
the treatment of all classes of patients on whom any of the proteiform varie-
ties of cutaneous affections may exist. The author draws largely — almost
exclusively — from the rich stores of his own scientific researches and his prac-
tical experience; and there is an unction of originality, blended with profound
and enlarged erudition, which gives a refreshing charm to the work, from
beginning to end. No mere speculative views are allowed a place in this
volume, which, without a doubt, will for a very long period, be acknowledged
as the chief standard work on Dermatology. The principles of an enlightened
and rational therapeia are introduced on every appropriate occasion. The
general practitioner and surgeon who, peradventure, may have for years
regarded cutaneous maladies as scarcely worthy their attention, because, for-
sooth, they are not fatal in their tendency ; or who, if they have attempted
their cure, have followed the blind guidance of empiricism, will almost
assuredly be roused to a new and becoming interest in this department of
practice, through the inspiring agency of this book. We speak not extrava-
gantly when we say that the learning which pervades and characterizes this
treatise, is so agreeably presented, that no medical reader having any claim
to* scholarship, or having any abiding desire for improvement and for profes-
sional usefulness, can fail to reap a large benefit for himself and for his
patients, by a close study of its doctrines, and a careful observance of its
practical directions and suggestions in matters appertaining to the general
and topical management of diseases of the skin. The untiring zeal and
commanding talents of Wilson will draw many disciples after him. This is
as it should be. They will find him no uncertain, flickering taper ; but a
clear and brilliant light, shining with steady radiance, and guiding their
steps in safety. And they will also learn, if they do not already understand,
that no man can be a skilful practitioner in Dermatology, unless he is some-
thing more than a mere specialist. He must be endowed with enlarged
views and varied knowledge and sound judgment in the several branches of
learning that constitute a thoroughly educated physician and surgeon.

1857.]

437

BIBLIOGRAPHICAL NOTICES.

Art. XVII. — Transactions of State Mtdical Societies.

1. Transactions of the Medical Society of the State of New York, transmitted to
the Legislature, Feb. 9, 1857. 8vo. pp. 292.

2. Proceedings of the Sixty-Fourth Annual Convention of the Connecticut Medical
Society, May, 1857. 8vo. pp. 71.

3. Transactions of the Eighth Annual Meeting of the Medical Society of the State
of North Carolina. Held at Edenton, N. C., April, 1857. Wilmington, N. C,
1857, pp. 90, 8vo.

4. Transactions of the Medical Society of the State of Pennsylvania at its Annual
Session, held in West Chester, Chester Co., May, 1857. 8vo. pp. 218.

1. The several addresses, biographical sketches, and professional papers,
embraced in the Transactions of the New York State Medical Society, at its
session of February, 1857, are of a highly interesting character. Nearly all
of the latter are replete with instruction, presenting the results of direct per-
sonal observation, or hints eminently suggestive on subjects of deep import-
ance to the medical practitioner.

The semi-annual address, delivered before the State Society by Dr. Alden
March, presents a rapid sketch of the progress, in this country, of agriculture,
commerce, the arts and sciences generally, during the last fifty years, in com-
parison with the advancement, during the same period, of every department of
medicine, whether considered as a science or an art.

The semi-annual address before the Medical Society of the County of Albany,
by Dr. Sylvester D. Millard, is devoted to a brief historical sketch of the Society,
with notices of some of those who have been its prominent and most efficient
members during the last half century, but have passed from time to eternity.

Both of these addresses are filled with matter that cannot fail to interest and
instruct all who feel a pride in the onward march of our profession, and its
increased facilities for the accomplishment of its mission of benevolence, or
are curious to learn something of the characters and career of those who, in
times gone by, constituted the leading members of the profession in one of the
most ancient cities of our Union.

To these addresses succeed biographical sketches of Drs. Moses Hale, John
McClellan, and Henry Mitchell, deceased members of the New York State
Medical Society.

The first of the strictly professional papers is on cholera infantum, diarrhoea,
and entero-colitis — their relation to each other, and their treatment — by Dr.
Edward Parker of New York City.

Dr. Parker examines each of the three following propositions, being those
generally received by the profession, or, at least, generally laid down as proved
by our systematic writers on the subject: —

" 1st. Cholera infantum is a disease peculiar to this country, though not
entirely unknown in Europe.

"2d. Cholera infantum is almost entirely confined to large cities, and is
rarely seen in the country.

" 3d. The symptoms, course, and pathology of the disease, entitle it to a
separate place in our nosological tables.

"4th. The treatment is to be distinct from that of diarrhoea, on the one hand,
and of dysentery on the other.

" 5 th. Perhaps the most alarming symptoms are those of hydrocephalus,
occurring in the advanced stages."

The correctness of all the foregoing propositions is denied by Dr. P. He

438

Bibliographical Notices.

[Oct.

adduces the descriptions given by Dr. West, of London, of inflammatory diar-
rhoea, and by Dr. Bouchut, of Paris, of infantile entero-colitis, which, in all
their essential features, will certainly represent, very accurately, a well marked
case of cholera infantum. There can be no doubt that a disease identical with
that known among us as cholera infantum, does prevail, to some extent, in dif-
ferent portions of Europe. It is nevertheless true, that infantine cholera is the
especial endemic, during the hot season, of the larger cities of our Middle,
Southern, and Eastern States, and that nowhere else does it prevail to the same
extent, and is productive of an equal amount of mortality.

That cholera infantum is in a great measure confined to our larger cities,
and to the most unhealthy, confined, and overcrowded localities within these,
is a fact so clearly demonstrated by a series of reliable mortuary statistics,
that we were somewhat surprised to find it so pointedly denied by Dr. P. The
evidence he has adduced to sustain his denial, is particularly loose and incon-
clusive. No dependence is to be placed upon the census returns quoted by
him, as, in the year to which they belong, instead of only 260 deaths occurring
in the entire State of Pennsylvania, the reports of the Board of Health show
a total of 505 for Philadelphia alone. But we do not deny that the disease
may occur out of cities. Wherever children, about the period of their first
dentition, are exposed to an intense heat, and, at the same time, to an impure,
damp, and stagnant atmosphere, and are badly fed, and lodged at night in
crowded, filthy, and ill-ventilated apartments, whether in or out of the city,
they will be liable to an attack of cholera infantum; but as this concurrence
of morbific agents is more commonly met with in the narrow courts and alleys,
and the badly constructed and overpopulated dwellings of the poor, in large
cities, it is there that the disease prevails every summer, and is productive of the
greatest mortality.

We have no disposition to deny the correctness of Dr. P.'s conclusions in
regard to the third proposition as stated above. Cholera infantum is unques-
tionably only an aggravated form of infantile diarrhoea; it is admitted, on all
hands, to be, in its second stage at least, essentially an entero-colitis, produced
by the particular morbific influences already referred to. This is proved beyond
the possibility of doubt by the pathological researches of Dr. Edward Hallowell,
of this city. (See this Journal for July, 1847, p. 40, et seq.)

Although, in its first stage, cholera infantum consists simply in an in-
creased and somewhat altered secretion from the mucous follicles of the intes-
tines, yet as this is very speedily succeeded by more or less extensive inflam-
mation, we agree entirely with Dr. P. that the general indications for the treat-
ment of the disease are the same as in diarrhoea and entero-colitis; recollecting,
however, that as the main agents in the production of cholera infantum are
intense and continued solar heat, a damp, confined, and vitiated atmosphere,
and improper food, regular and continued exposure of the patient to cool, dry,
fresh air, and a well regulated, wholesome diet, are of primary importance to
insure a speedy cure: with these, and daily bathing in warm water, a very sim-
ple course of positive medication will be demanded; without these hygienic
measures, all other remedies, however well selected or assiduously administered,
will fail to produce any permanent good.

There can be no doubt that, in very many cases of cholera infantum, the
cerebral symptoms which are attendant upon the advanced stages of protracted
cases, are the result of exhaustion and anaemia, and not of meningeal inflam-
mation. We have, nevertheless, had occasion, in numerous instances, to ob-
serve, at a somewhat early period of the attack, all the symptoms of acute
meningitis to present themselves, and terminate promptly in effusion. That in
these cases, the cerebral symptoms were the result of meningeal inflammation,
was shown by repeated examinations after death.

A very sensible and opportune paper on " Improvements of the Public Health,
and the Establishment of a Sanitary Police in the City of New York," is from
the able pen of Dr. John H. Griscom.

Public hygiene, though calculated, when systematically and rigidly enforced,
to promote the health, comfort, and pecuniary interests of every community —
to eradicate most, if not all, endemic diseases that prevail in their midst, and

1857.]

Transactions of State Medical Societies.

4S9

to protect, to a very great extent, against the incursion of even the most fatal
and dreaded epidemics, or, when these make their appearance, to disarm them
of much of their malignancy, and reduce the number of their victims — is
scarcely recognized as a legitimate subject for legislative or executive action.

" The great and serious fact," very pertinently remarks Dr. G., " seems
scarcely yet to have penetrated very deeply into the spirit of government and
legislation, that there is such a thing as sanitary science; that the object of this
science is the ascertainment of the laws of health and disease, and of the cir-
cumstances which promote and control them ; that though comparatively in its
infancy, and demanding for its advancement all the time and talent we can
bring to bear upon it, it is still so far understood as to enable us to make a
practical application of its principles to the prevention of disease, and the pre-
servation and prolongation of life ; and here let me say, that it is not in the
light of epidemics alone that this science is properly received ; in the truthful
language of a contemporary writer, the public are too apt to • lose sight of the
less violent, slower, but no less certain causes of sickness and death with which
they are continually surrounded. Death reaps a yearly harvest to the grave,
and when it exceeds not the usual number it is not heeded, and the inquiry is
not made whether a part of his trophies might not have been snatched from
him.'1 While it is the direct purpose of sanitary science, and the legislation
which should flow from it, to reduce the draughts of death by preventing epi-
demics not only, but all the minor disorders also by which he gathers us in.

" Sanitary science, while directly allied to, and forming a part of the great
science of medicine, is in a measure distinguished from it in its peculiar rela-
tions to mankind, and in the application of its laws for their relief. Both re-
quire a thorough knowledge of physiology, or the laws of life ; of practical
chemistry; of the symptoms, causes, and treatment of disease, and of patho-
logy, or the laws of morbid action. But for the sanitarian physician, super-
induced upon these, there is especially requisite a knowledge of forensic medi-
cine, or the relations of the science of medicine to law; of meteorology, or the
effects of climate and atmospheric influences on the body; of the physical cha-
racter or dynamics of the atmosphere ; of the philosophy and practice of venti-
lation ; of various matters of a mechanical kind bearing on sewerage, house
building, street cleaning, and water supply ; of statistics of life and mortality ;
of the literature of epidemics, and of all sanitary improvements. And, lastly,
to be a good sanitarian, requires the possession of sound logical faculties ; the
capability of dealing with facts and opinions without mistaking coincidences
for causes, or building up great theories on insufficient data, or from great facts
deducing absurd conclusions. Thus it will be seen that one may be a good
practising physician without being a sanitarian, but no one can be a good sani-
tarian without being a good physician ; the requisites for one underlie those
for the other, as a foundation."

" The very first duty which should be required of an officer of health is,
vigilance in the discovery of the actual existence of disease. He must be a de-
tective policeman, and must therefore be familiar with the appearance of
disease of every kind; as upon his diagnosis may depend the loss or salvation
of many lives, and large amounts of property. Who but a well educated phy-
sician, therefore, is competent for this first of all sanitary duties?

" Presupposing this qualification, let us glance further at his duties ; they
may be stated as follows: to ascertain and make reports as to the sources of
disease, or the circumstances which promote their diffusion among the popula-
tion; to define the districts in which they spread ; to ascertain the character of
the streets and houses in such districts ; to describe the nature and extent of
the internal accommodations of the dwellings of the labouring classes, how
much they may be overcrowded, and of their means of securing cleanliness,
removing filth, promoting ventilation, and providing warmth with economy ; to
discriminate between the direct influence upon their sanitary condition of the
habits of the poorer classes and the external circumstances by which they are
surrounded, while avoiding the error of supposing those habits to be inde-

1 Newman, Report on Sanitary Police.

440

Bibliographical Notices.

[Oct.

pendent of other domestic arrangements ; to ascertain whether any and what
injurious consequences are clearly attributable to certain manufactures ; to the
location of slaughter-houses, tanneries, burying-grounds, &c, amidst dense
populations; to distinguish the extent of disease caused by removable agencies ;
by malaria from defective drainage, by bad construction of dwellings ; and by
destitution of the means of subsistence; to ascertain from personal observation
the condition of the soil, its geological nature, and power of absorbing and
retaining moisture ; the extent of the supply of water for public purposes and
domestic uses; and the quality and extent of the sewerage; to advise and re-
commend measures for purification and improvements in all these matters ; to
ascertain the existence of particular diseases which increase the ordinary rate
of mortality, as well as keep thoroughly informed as to the general and rela-
tive mortality of the district : in a word, to have a perfect knowledge of the
sanitary state of the inhabitants, and to keep a watchful eye upon all its
changes, so that a perfect system being introduced, the routine of daily labour
and daily cleansing should prevent any accumulation of noxious substances,
and render unnecessary any cleansing works of magnitude to meet extraordi-
nary visitations of disease. Connected with which duties would be the
inspection of all public buildings, churches, poor-houses, hospitals, asylums,
lodging-houses, tenant-houses, so called public and private schools, and chari-
table institutions ; the pointing out of means of insuring adequate supplies of
pure air, and of exit for that which is vitiated ; and the keeping of records of
meteorological changes, and studying their relation to the appearance and pro-
gress of disease.

" To sum up the whole, of which the above is but a partial enumeration, an
officer of health should be duly qualified and required to act as the efficient me-
dium by which all the circumstances which affect the health of man — and their
name is legion — may be duly considered and weighed ; to classify and arrange
them, that they may be brought under simple heads, and consequently be more
easily remedied either by voluntary efforts or legislative enactments, so that
all classes, both rich and poor, may be relieved from the cruel alternative of
being compelled to submit to deleterious and destructive influences or of being
turned out of their dwellings, which, though unwholesome, are still their
homes. "We need scarcely add, that the sanitary department of every city
should be empowered by law to enforce all measures calculated to promote
these important results.

" There are yet two other points in which the services of properly qualified
and authorized sanitary officers might be of invaluable benefit to the people,
especially the poor ; who we now know suffer immeasurably in purse and
health, and are without remedy. These are the detection and exposure of
adulterations and impurities of food and medicine. The extent to which these
fraudulent operations are carried is scarcely credible, and cannot be under-
stood except by the initiated."

" Having fixed in our minds this theoretical view of what should be accom-
plished with a corps of properly qualified functionaries, let us next see the
materials for such a force; whether it is possible to find men of the required
capacity and intelligence, and whether their services are obtainable, a brief
statement of facts confined to the city of New York, but applicable elsewhere,
will satisfy both inquiries.

" Besides the existing department, which is supposed to have a supervision
over sanitary matters, we have another institution devoted to the same general
object, viz : the protection of the health of the people, in the service of which,
supported partly by public and partly by private bounty, are employed in its
out-door duties a staff of some fifteen active and intelligent medical men. The
institution here referred to is the dispensary system of administering medical
aid to the indigent. The five dispensaries cover nearly the whole city. The
amount of good work performed by the physicians of these institutions cannot
be expressed in figures, but some idea of it may be obtained from the fact that
they administer professional relief annually, at their dwellings, to about
22,500 persons, making in one year, at the lowest estimate, 67,500 domiciliary
visits to these destitute people, living as they almost invariably do in cellars,

1857.]

Transactions of State Medical Societies.

441

attics, courts, alleys, and crowded tenements, in the most degraded and filthy
portions of the city." " Here, then, we have a body of men not only con-
tinually cognizant of the diseases which threaten the people's lives, and in con-
tention with those diseases to preserve those lives, but more important still
they have a personal knowledge of their sources, and are personally and deeply
interested in their abatement. Their duties call them to the very localities in
which pestilential diseases first make their appearance ; they are the first to
recognize their existence, it is their duty to combat them ; and theirs should
be also the power to exert all the force which science and law can furnish to
check the evils in the bud.

" Thus is the question answered whether there can be found men capable
and willing to act the part demanded of a model sanitary officer. For half a
century just such a body of men has been quietly and unostentatiously per-
forming this great work of humanity, and all the valuable aid which the city
might have derived from them, in addition, as public officers of health, has
been overlooked and despised. There cannot be a question that, had the two
systems of preventive sanitary police, and dispensary medical aid been united in
one, under an energetic administration, during the period of their mutual ex-
istence, the expenses of both would have been many, many times saved,
together with innumerable lives. But, instead of this, while the dispensaries,
which are private institutions, though performing a most important public
function, have advanced in usefulness and dignity with rapid strides, the pub-
lic health department has degenerated almost as rapidly as the other has risen,
until at last it has become a by-word and reproach among all classes of citizens.
Of the causes of this we need say no more, in addition to what has already
been hinted, than that it is due in great measure to the absurd practice of
mingling science and humanity with politics ; as rational would it be to choose
our dispensary and hospital physicians by general election from among the
mercantile and mechanic classes, as to select our public guardians of health
from those sources, and in such a manner as is now done."

On the types of fever, by Dr. George Burr, of Binghampton, is the title of
the next paper.

Dr. Burr defines the term type as applied to fever, to signify a peculiar form
or character of the disease which distinguishes it from other varieties of fever,
and which, when correctly determined, gives us a more correct and definite
idea of the nature of each particular case that comes under observation. Every
form of fever possesses certain symptoms common to all, which have been
received as the especial febrile symptoms ; now these symptoms may be so
grouped, or exhibit such peculiarities either in violence, duration, regularity,
location, &c, as to indicate unmistakably a radical difference in the nature
and efficient cause, in the various forms of fever which are, from time to time,
to be observed. These several groupings or classifications of febrile manifesta-
tions enable us to distinguish one form of fever from another, or in other
words determine its type.

With this very loose and unsatisfactory definition of type, Dr. B. proceeds
to consider the malarial or intermittent type of fever, including bilious remit-
tent, congestive, and pernicious fevers, and the yellow fever, which he considers
a distinct type. The continued type of fever he reserves for a future com-
munication.

The remarks of Dr. B. on the symptomatology, pathology and causes of
malarial fever, and his concise notice of yellow fever, are in the main correct
and pertinent; we find in them nothing, however, particularly novel or
striking.

It is a general opinion among American physicians that periodical fever is
less prevalent of late years in what have been considered as well-marked
malarial regions, and that fever of a typhoid character now predominates in
many of those districts of country of which intermittents and remittents were
formerly the especial endemic. From this opinion Dr. B. dissents. He believes
that the fever now recognized as typhoid by many of our physicians, is in its
type essentially malarial, and for the following reasons : —

" 1st. It prevails in the latter part of the summer and during the autumnal

442

Bibliographical Notices.

[Oct.

months more generally — sometimes in the spring, corresponding to what are
termed vernal intermittents. It is often accompanied by dysenteric symptoms,
and in that form sometimes resembles an epidemic.

"2d. Bilious symptoms predominate. The tongue is usually coated heavily,
there is more or less nausea, and the stomach often loaded with vitiated bile,
and the invasion of the disease is marked by rigors, followed by febrile reaction,
with, in most instances, distinct remissions, during which the skin is bathed
in perspiration ; at other times the fever seems more continuous, and the period
of remission hardly perceptible. This is more particularly the case where the
force of the attack is directed against some particular organ, as the brain,
lungs, or gastro-enteric membrane, &c.

" 3d. These cases are best treated by the early administration of quinine, given
during a remission of the febrile symptoms. My own observation, and the ex-
perience of others in a somewhat extended acquaintance, justify me in making
this point. When given at the proper stage, the whole febrile movement
becomes modified, and in due time disappears, without that prolonged condi-
tion which some have called the typhoid stage of the disease.

" It is not intended to deny the existence among us of that form of con-
tinued fever denominated, by Louis, typhoid fever. It is, I believe, however,
very rare, and is to be met with under very different circumstances from those
which accompany the form of fever we have been regarding."

A case of death by syncope, from plugging of the pulmonary artery, reported
by Dr. 0. M. Allaben, is in many points of view a highly interesting one. It
will be noticed in another department of this No.

Dr. W. S. Norton, of Fort Edward, relates a case of gangrenous erysipelas,
involving the whole of the right hand and arm to the elbow-joint. It occurred
in a young lady, twenty-two years of age, and was treated by free longitudinal
incisions through the gangrenous parts ; the subsequent application of a strong
" terebinthinated tincture of cantharides," over the entire arm, followed by
poultices, thirty grains of calomel, with five of opium internally, and the free
use of brandy punch.

Under this treatment, the case progressed favourably, and at the end of one
month from the commencement of the attack, the patient was entirely well,
with the exception of an inability to flex and extend freely the fingers of the
right hand.

The treatment pursued in this case was, under the circumstances, judicious;
we do not consider it of so novel a character as Dr. N. would seem to infer.

A case is detailed by Dr. Nelson Winton, of Havana, in which an ovarian
tumour was successfully removed by extensive abdominal section, with recovery
of the patient.

A case of medullary sarcoma in the knee-joint, in a girl twelve years of age,
in which amputation of the limb was resorted to, is related by U. Potter. It
presents no points of especial interest.

To these cases succeeds a paper by Dr. D. P. Bissell, presenting some general
remarks on the importance of the adoption of effectual means for the extension
of full, efficient vaccination to the entire community, as the only sure protec-
tion against smallpox ; and on the necessity of securing to physicians a con-
stant supply of pure, reliable vaccine matter. The remarks of Dr. B. under
both heads, are sound and pertinent.

He suggests that depots of vaccine virus should be established and main-
tained in some one or more of our principal cities, where physicians may at all
times obtain a supply.

Dr. C. V. Barnett reports a case of supra-malleolar amputation in a case of
gangrene of both feet from the effects of frost, and appends the following re-
marks on the relative vaUie of amputation at this spot : —

" To comprehend its full value when compared with amputations at the usual
place of election, we have only to take into consideration that the limb is divided
at a point where the lower end of both bones has attained its largest size, and
where every muscle of the leg has become tendinous, and above all, every ten-
don takes a ready and firm attachment to the end of the bones. From this it
necessarily follows, that in the application of an, artificial limb, you have the

1857.]

Transactions of State Medical Societies.

443

whole weight of the body supported by the attachments of these tendons, in-
stead of the small pointed ends of the bones continually jamming into a tender
mass of flesh, as in case of amputation in the fleshy portions of the leg."

The following case of hemorrhage from the urethra, is related by Dr. N. C.
Husted : —

" Mr. C, aged 42, of medium height, healthy, and robust, of a nervo-san-
gnineous temperament; never has had any urethral difficulty. Whilst having
an intercourse, he was seized with severe pain about midway in the penis, as
he described it; he arose, and found the blood flowing in a full stream from
his penis. He laid down again, supposing the hemorrhage would cease, but it
did not. He became faint, and sent for me. I prescribed cold to the penis and
perineum, and, internally, tinct. ferri muriat., in doses of ten drops every hour,
until the hemorrhage ceased. It subsided soon, and in a week he was able to
go to his work. Nothing of the kind has occurred to him since.

" I find but one case of the kind recorded, which is very similar in every re-
spect; it is reported in the American Journal of Med. Sciences for Oct. 1850."

The scientific contents of the volume before us, conclude with the history of
an interesting case of chronic tubercular splenitis, resulting in abscess, or en-
tire disorganization of the parenchyma of the gland, communicated by Dr. G.
J. Fisher, of Sing Sing. On examination after death, there were discovered
hypertrophy and dilatation of the heart ; miliary tubercles throughout nearly
every portion of the lungs; enlargement and induration of the liver; its sub-
stance beset with tubercles from a microscopic size to that of a small pea.

" The spleen was carefully separated from its surrounding attachments, which
were old and strong, apparently the result of adhesive peritoneal inflammation;
its bulk was about four times the natural size, it was of an oval shape, and,
when removed, was discovered to be distinctly fluctuating. On laying it open
by a free incision, it was found to consist of a mere sac, the walls of which did
not exceed an inch in thickness, though not entirely uniform throughout. This
sac contained a liquid or semi-fluid disorganized mass, which appeared to con-
sist of pus, and the broken down or disorganized parenchyma of the spleen ;
from the centre to the surface of the organ, every stage of the process of dis-
organization was to be seen from pus to the slightly changed substance of the
gland. The remaining organs of the abdomen presented no marked pathologi-
cal changes, except the deposit of tubercular matter in the layers of the mesen-
tery, and the enlargement of many of its glands."

2. The several addresses, dissertations, and reports, embraced in the pro-
ceedings of the annual convention of the Connecticut Medical Society, held
May, 1857, are replete with sound principles, noble sentiments, and useful
observations, many of them of deep interest to the members of the profession
associated with the Connecticut Society, but not of that general character which
would press them strongly upon the attention of those beyond its circle.

The annual address by the President, Dr. B. H. Colton, presents a hasty
sketch of the history of the Connecticut Medical Society, suggestions for the
increase of its efficiency, and for the enlargement of its sphere of usefulness,
with an occasional remark on the practice of medicine throughout the State.

In a well written and manly expressed dissertation, by Dr. Benjamin F.
Dean, is presented, in brief outline, the history, present position, and pro-
spective attainments of the medical profession.

A dissertation by P. M. Hastings is occupied mainly with very excellent and
pertinent remarks on the value of the microscope in our investigation of the
structure and functions of the animal organism, and as a means of diagnosis
in disease.

From the sanitary report from Hartford by Dr. Gordon W. Russell, we quote
the following, which is a portion of the reporter's able remarks on the sub-
ject of vaccination generally.

" The propriety of using the scab or crust for vaccination, instead of the
lymph taken about the sixth or seventh day, may well be doubted ; not but that
a good crust, consisting of hardened lymph, will equally communicate the dis-
ease, but the difficulties and uncertainty of obtaining a crust consisting of

444

Bibliographical Notices.

[Oct.

lymph alone, becomes an objection. Frequently the vesicle is broken and the
lymph nearly discharged, or, in consequence of inflammation, the crust con-
sists in part of dried purulent, or semi-purulent matter which may produce a
sore, but not always a vaccine vesicle, and which, if not carefully examined on
the fifth day, may be thought to be a genuine one. And here I may be allowed
to suggest the propriety of testing all cases of primary vaccination ; this would
afford a sure and perfect guarantee of the protection given by the first. It is
attended, I admit, with some trouble, but if the fee is not already remunera-
tive, it should be made so."

" That revaccination is a necessary operation, protecting the system alreachr
wholly or partially exposed to variolous infection, is, I believe, generally ad-
mitted, though still denied by some physicians. I confess I have rarely seen
a perfect vesicle in a secondary vaccination, when there was already a well-
defined, punctated scar from the first. I have occasionally seen near approaches
to it, varying, however, in the constitutional symptoms, in the appearance of
the areola, and of the attendant inflammation ; some of the profession, I know,
are reported to have seen it frequently, but I have not been so unfortunate, the
nearest approach to it that I have seen this season, was in a lady of at least
sixty years of age, who had been inoculated with variolous matter in Scotland
when a child.

" Of course, the crust that is formed during these revaccinations, should
never be used for the purpose of producing the vaccine disease. It might occa-
sionally answer for the purpose, and of course it would do so whenever it is
the product of a genuine vesicle, but these instances are so rare that it is
safe to lay it down as a rule that it should never be used.

" I am satisfied that variola is upon the increase, and for years to come will
continue to increase, until public necessity shall compel a resort to careful,
general, and repeated vaccination. The time may not yet have arrived, when
by public authority every child shall be vaccinated before it is three months of
age, but when this foul disease shall have become more common, every one
perceiving the increase of it, then may we expect such a consummation, and
that the law will not be a dead letter."

" There is an interesting portion of this subject, itself alone sufficient for a
lengthy dissertation, viz., upon the communicability of disease by vaccination ;
this demands careful and thorough investigation, both to satisfy ourselves, and
quiet the public feeling, which is strongly inclined to believe in its truth.
Without denying the possibility of it, I am still somewhat skeptical as to its
frequent occurrence; though cutaneous disease may occur after its performance,
and be the indirect result of it, as vaccination often develops any tendency to
disease of the skin, which may be present in the system. I can now recall
but one instance in which I have witnessed any cutaneous eryption to follow
vaccination this season ; this was eczematous in its character, and appeared
about the tenth or twelfth day of the operation, behind the ears and upon the
lower part of the scalp. The child was teething at the time, which was enough,
in my opinion, to account for it; and that it was owing to this, and not to the
vaccine infection, was shown by the same matter being used in quite a number
of instances, before and afterwards, without any such result being produced.
If physicians would make a careful record of all such cases that come under
their notice, a mass of information would be obtained, which would enable us
to dispel many of the illusions of the public.

" The popular notion that vaccination should be repeated at every certain
and defined period of one's life, is altogether wrong; there can, with reason,
be no such course marked out ; but if the operation was done during infancy,
it is proper that it should be tested after the subject has grown up. If any-
thing further than this is done, it must be as much to satisfy the wishes and
quiet the fears of the timid, as to comply with any rule indicated by reason or
experience."

Besides the papers noticed above, the volume before us contains biographical
sketches of Dr. Eli Hall, of East Hartford, and Dr. Sylvester Bulkley, of Rocky
Hill. The first of these gentlemen died June 8, 1856, in the 71st year of his
age, and the second, February 1, 1856, in the 69th year of his age.

1857.]

Transactions of State Medical Societies.

445

3. The Transactions of the Medical Society of the State of North Carolina,
at its session of April, 1857, contain many interesting papers.

The first of these is a report on Stomatitis materna, by Dr. Wm. H. McKee,
of Wake County.

The disease, Dr. McKee states, has appeared in sporadic cases, in his vicinity,
for several years past. Its first symptoms, as observed during the latter period
of pregnancy, are an inflamed and extremely sensitive Btate of the mouth and
tongue, rendering salt food and acids intolerable. There is, at the same time,
loss of taste, impaired appetite, thirst, with insomnia, or disturbed dreams.
In a few days, isolated patches of ash-coloured sores appear on the lips, cheek,
and tongue, with a free discharge of saliva. Under proper treatment, all these
symptoms soon disappear, but, in most cases, return after parturition ; gene-
rally towards the end of the second or between that and the close of the fifth
week. The. soreness of the mouth and tongue is now of a more aggravated
grade. The sores are petechial, and soon become confluent, the tongue fissured
and swollen, with increased salivation. The patient cannot take sufficient
nourishment, the secretion of milk is imperfect, and suckling is attended with
pain and great fatigue. The imperfectly nourished child, becomes fretful and
restless, and deprives the mother of comfort and sleep. Fever soon sets in.

Dr. McKee remarks that, in every bad case he has met with, there was flood-
ing subsequent to delivery, and a too free discharge of the lochia.

The child, we are told, should now be weaned, and every effort made to im-
prove the condition of the digestive organs of the mother.

After the healing of the ulcers, the mouth and tongue have a glazed and
polished surface, and become less sensitive to articles of food. The patient
craves the coarsest diet which alone seems to satisfy her appetite. This, after
from twelve to sixteen hours, is thrown up either inodorous or decidedly acid.
As the disease subsides in the mouth, the stomach and bowels become affected,
and there is vomiting, with occasional purging, pain of abdomen, restless
nights, emaciation, colliquative sweats ; the skin being pale, as it were blood-
less, of a pearly whiteness, drawn tightly over the bones, and appearing as if
polished ; in other cases it has a dark, dry, shrivelled appearance. The ab-
dominal symptoms being partially relieved, the disease shows itself at the
verge of the rectum and soon spreads to the vagina, urethra, and womb. The
sphincter ani becomes fissured, and a crop of ash-coloured sores surrounded
the anus. Defecation is intensely painful, the feces hard and coated with
blood and mucus. So severe is the suffering now, that patients have declared
they would much rather give birth to a child, than endure a passage by stool.
Leucorrhoea of an acrid character attends, and adds to the complication of the
disease and the sufferings of the patient. The mouth and fauces become now
anew the seat of disease, which extends to the frontal sinuses and facial antri,
and, finally, to the lungs, inducing cough, expectoration, pain, night-sweats,
and finally dropsical infiltration, succeeded by death.

In regard to treatment. The infant should be weaned if possible. A blue
pill followed by a mixture of calcined magnesia and Hoffmann's anodyne, of
each one drachm, suspended in sugar and water, will afford great relief. As
a local application to the mouth, creasote is one of the best ; it may also be
given internally with good effect. We may also employ a solution of chloride
of soda, decoction of smart weed, sage and alum with honey, olive oil and
honey, etc. The internal use of iron is our best remedy ; by combining it
with iodide of potassium its virtues are much enhanced. The tincture of
chloride of iron is a favourite remedy, but the preparation that Dr. McKee has
found the best, is the tartrate of iron and potassa, in combination with the
iodide of potassium ; two drachms of each to eight ounces of Madeira wine
and the same quantity of water, taken in the dose of a dessert-spoonful, three
times a day — with the free use of morphia at night to control pain and procure
sleep ; purging with magnesia and an anodyne when required. For the vomit-
ing— the tinct. nux vomica, twenty drops for a dose, in cold water, was gene-
rally successful. The patient should take the air whenever able to do so.
When there is emaciation, the cod-liver oil may be given with porter, brandy,
or whiskey, when the stomach can take it. When the rectum is the seat of

446

Bibliographical Notices.

[Oct.

disease, anodyne injections are indispensable. For the leucorrhcea, the solu-
tion of acetate of zinc, four grains to an ounce of water, by injection, having
first used •warm water and castile soap, will arrest promptly the discharge.

Stomatitis materna has been supposed by some to be caused by a defibrina-
tion of the blood from the use of water impregnated with an excess of lime.
Dr. McKee remarks, however, that the section of country in which his cases
occurred was a high and healthy granite ridge, affording freestone water of an
excellent quality. Besides, a good many cases occurred in the rural districts,
where the purest air and water exist.

A valuable report is presented by Dr. H. Kelly, on the diseases most preva-
lent in Iredell County, from May, 1856, to May, 1857.

The report of Dr. J. J. Summerell, on the diseases of Rowan County, contains
three very interesting cases; one of fracture of the skull, with injury of the
brain. The patient recovered perfectly at the end of three months from the
receipt of the injury. A second, of compression, from extravasated blood, of
the brain, without fracture of the skull, the result of a fall. The skull was
trephined, the extravasated blood removed, and the patient ultimately recovered
entirely. The third case we give entire ; it is one of delirium tremens follow-
ing an attack of pneumonia.

In the report of Dr. X. J. Pittman, on the diseases of Edgecomb County, we
find some instructive remarks on epidemic dysentery and its treatment, and
several instructive surgical cases.

The most extended and elaborate report in these Transactions is that of Dr.
Otis F. Manson, on malarial pneumonia.

The reporter examines very minutely the general course and progress of
pneumonia, as it usually occurs in malarious districts, its physical signs, and
the physical changes that occur in the disease ; the diagnosis between it and
the other forms of pneumonia ; its cause and nature, and the treatment best
adapted to conduct it to a favourable termination.

The report is one we should like to dwell upon at some length. The author
has emitted opinions which are eminently suggestive, to say the least of them,
and certainly deserving of a close and candid examination. The correctness of
some of his conclusions may admit of question, still as a very masterly history
of pneumonia, in the form under which it usually presents itself in those whose
systems are labouring under the influence of malarial poison, it forms certainly
a valuable contribution to pathology. We can spare space only for the follow-
ing extracts, from which a tolerably correct idea will be obtained of the general
views of Dr. Manson in relation to the true character of what he terms, with,
we think, some degree of looseness, malarial pneumonia : —

"The doctrine that this form of pneumonia owes its existence to malarial
influence has long been entertained and acted on ; but, on the other hand, has
been as strenuously contested, both in regard to its correctness and legitimate
consequences. The subject is one of great interest and of the highest import-
ance, involving unquestionably the lives of the inhabitants of many sections of
our own and other countries. The reader who has had frequent opportunities
of observing remittent fever at the bedside, or those who have not, who have
known the writer, by a perusal of his imperfect descriptions of that disease,
cannot fail to perceive the close resemblance between the phenomena presented
by that affection and the disease under consideration. Indeed, the similitude
is almost perfect, with the addition of the signs and symptoms of the thoracic
lesion. It will be observed, therefore, that the evidences of organic implica-
tion are by no means confined to the organs of respiration, that symptoms of
gastro-intestinal disorder very frequently preceded the lung symptoms, and that
both were very often preceded by febrile excitement for hours and even days.
We have seen that the patient evidently does not always perish from the patho-
logical changes wrought in the lungs; death more often occurring from the
supervention of fierce delirium, not only independent of the lung affection, but
subsequent to its abatement or total disappearance. These facts, then, clearly
denote the connection between this disease and periodical fever, as they suffi-
ciently prove that its phenomena are not merely symptomatic of lesion of the
lungs.

1857.]

Transactions of State Medical Societies.

447

" By some, an explanation of the existence of this disease has been given by
attributing it to the combined agency of malaria and atmospheric vicissitudes.
This is doubtless often true, but it does not offer a satisfactory solution of the
fact that many are often attacked with it who have not been exposed in any
appreciable degree to those changes. Indeed, this affection often attacks a
number of persons, consecutively, in the same household, with intervals of time
elapsing between the occurrence of the cases to permit all conditions of tem-
perature and humidity to appear properly belonging to the season. ' It is
probable/ says Laennec, ' that the epidemic peripneumonia is often owing to
the deleterious miasms which have entered the system by means of the cuta-
neous or pulmonary absorbents, since nothing is more common than to meet
with cases of this disease to which we can assign no occasional cause. — How
many persons are seized with it in their very chambers, and in spite of the
utmost care taken of their health/ It is impossible that any observer of ordi-
nary perception can have failed to be often impressed with this reflection. Ex-
posure to atmospheric alternations does not, therefore, offer a complete and
satisfactory explanation of the general occurrence of this affection. I propose,
with some diffidence, to offer a few simple thoughts on the subject. It is a fact,
which will scarcely be questioned, that during the prevalence of any fever, in
seasons of low temperature, pulmonary inflammation is prone to occur as a
complication. In scarlatina, rubeola, typhoid fever, and other febrile affections,
it is very common. There are some causes, therefore, existing and belonging
to the season, which either excite or predispose to lesion of the lung paren-
chyma. In instituting an inquiry into the operation of these causes, it will be
necessary to bear in mind that the system has passed through the fervid heat
of summer, the balmy temperature of autumn, by transitions more or less
variable, to the colder season of the year. Usually the outward man has been
prepared for this change, the entire skin surface having been protected from
the effects of reduced temperature by clothing of proper quantity and quality.
But how is it with the lungs, the only remaining surface, besides its outlet,
which is exposed to the direct contact of air? What has been done to protect
that extensive, delicate lining of the air- tubes and air-cells?"

"It is evident that this great annual change of temperature cannot take place
without some important physiological revolution in the pulmonary circulation ;
to understand t,he nature of which, it is only necessary to remember the usual
effects of reduced temperature upon vascular tissues in general. The first im-
pression on the lungs must necessarily be succeeded by contraction of their
capillary vessels. Happily, however, our organs are endowed with a certain
degree of resistance to depressing causes, under the operation of which the
vessels again expand and allow the free transmission of their contents. In
short, the equilibrium of health is established. This resisting force which thus
averts disease, or, in other words, the nervous force — the only power existing
in the system, of which we are cognizant — must, however, be continued and
maintained, in order that no embarrassment to the circulation may ensue;
consequently throughout the colder seasons a greater amount of nerve power
must be expended in the lungs to preserve their physiological condition. Again:
the effects of the reduced temperature will be in proportion, 1st, to its intensity
and duration; and, 2dly, the capability of resistance residing in the system.
If we suppose that the system is contaminated by the depressing influence of
malarial fever, or debilitated by its latent influence, it necessarily follows that
such a person must be in a favourable condition for the development of pul-
monary engorgement, from the fact that he is subjected to a temperature re-
quiring a healthy nervous force to resist, which he does not possess. There
is plainly, then, a degree on the thermometric scale, equivalent to disease with
him, yet compatible with health in others.

" Let us advance one step further. The degree of cold being present beyond
the nervous power to resist, or having endured so long as to have for a time
exhausted its resources, let us look again at the capillaries of the lung. If the
vessels, contracted by the application of cold, do not possess the normal resist-
ance vigour, as we have assumed as an axiom in the malarial diathesis, the
same or greater effect is produced than by a more intense degree of cold, acting

448

Bibliographical Notices.

[Oct.

on a healthy subject. Under ordinary circumstances, however, the nervous
centres will be stimulated to react — those cases attended with collapse in the
commencement being the exceptions — the reaction, according to a law of the
organism, being in proportion to the previous degree of depression. 'An in-
creased afflux of blood to the part consequently ensues, and as the action of
cold has indirectly produced the same effect as that produced by a direct irri-
tating cause, it will only be necessary to follow the subsequent steps in the
process to the state of active congestion, as detailed by Kaltenbrunner's micro-
scopic experiments.' But there is yet another function which has also to un-
dergo an important modification. The skin, which in the warm seasons had
been exalted to excessive activity, gradually falls into a state of comparative
repose as the bleaker season arrives. This evidently occurs, however perfectly
it may have been protected. This subsidence of function must necessarily be
followed by a determination of blood to the internal organs, the retrocession
being greater and more easily induced in malarial subjects, for reasons before
adduced. We have now an explanation of the modes by which cold and ma-
larial influence may act as exciting and predisposing causes of this affection ;
but this solution does not wholly apply to those cases occurring in previously
healthy subjects, whilst sedulously guarded from atmospheric vicissitudes.
These cases are evidently due to the evolution of malaria, the affection of the
lungs being produced by the predisposing tendencies of the season.

"Objection has been urged on many grounds to this view of the causation of
the disease, the principal one of which is that it prevails in seasons inimical to
the existence of miasmata. This is plainly an error. Primary attacks of pe-
riodical fever not unfrequently occur during the winter and spring months,
especially the latter, which is also the season in which this form of pneumonia
is usually prevalent. It is admitted that a form of disease similar to that we
have described often prevails as an epidemic. Now, whether it be regarded as
merely a complication, a compound, or as a hybrid affection, it cannot be dis-
puted that it rages in those seasons of the year, the temperature of which they
assume to be destructive to malarial influence. The inconsistency is obvious.

"The occurrence of periodical fever not only in the spring, but occasionally
in the winter months, being easily established, there are conditions necessary
to be noticed, closely associated with its nature and phenomena, which, besides
the tendencies of the season, assist in producing a sanguineous determination
to the lungs. In discussing the subject of remittent fever, I briefly endeavoured
to prove its nature from the character of the symptoms existing during life, and
to show that there was constant tendency in the vital current to retrocede from
the extremities to the trunk, and in grave cases from the whole surface to the
internal organs. Of the cause of that morbid afflux I then, as now, avoided
discussion. My opinion is that it is produced by an irritation of the nervous
centres, of a peculiar character. As a consequence of this irritation and con-
gestion, delirium, difficult locomotion, dyspnoea, independent of pulmonary
engorgement, with varying conditions of pulse, and abdominal symptoms, were
observed, accordingly as different portions of the cerebro-spinal axis may have
been involved.

" To sum up our reflections on the pathology and etiology of this form of
pneumonia, we have, to explain its production and phenomena —

"1. The predisposing tendencies of low temperatures to produce an afnux to
the lungs, by direct contact with their interior surface.

"2. The same cause, by repression of the cutaneous evacuations, determining
to the whole internal organs.

"3. The operation of malarial influence, which not only diminishes the vital
resistance to cold, but possesses an evident inherent tendency to produce in-
ternal engorgement."

" I have repeatedly stated my impressions in regard to the condition of the
lung parenchyma in this affection, as partaking rather of the nature of active
congestion than well-developed inflammation. This is proved, in my opinion,
by the following circumstances: 1. The sudden occurrence of solidification, as
evinced by perfect flatness on percussion, and absence of the respiratory mur-
mur. This sometimes takes place, in grave cases, in a few hours after its onset,

1857.]

Transactions of State Medical Societies.

449

involving more than half of the entire lungs, accompanied by a cold skin, flag-
ging pulse, and colliquative diarrhoea, a condition of system totally incompatible
with the existence of the inflammatory process. 2. The disappearance of the
physical signs is too rapid in many cases to suppose that inflammation, termi-
nating in plastic exudation, had produced this impermeable condition of the
lungs. It is true, as we have stated, that there are some evidences of inflam-
mation mingled with the symptoms ; and as active congestion is a state closely
allied to inflammation, the latter may, and doubtless does, occur ; but it is evi-
dent that inflammation cannot be the general condition, as it is too expeditiously
removed, in many cases of several days' duration, and by inadequate means, to
render that view admissible."

The annual address of Dr. S. S. Satchwell is a most able one. His picture
of medical science is admirably and truthfully drawn, while his exposition of
the causes which have in some measure impeded its progress, and reduced in
no slight degree the standing of the medical profession in our midst, are clear,
faithful, and impressive. We regret that want of space will not allow us to
present some extracts from this excellent address.

4. The present volume of the Transactions of the Pennsylvania State Medi-
cal Society is, in several respects, less interesting than some of the preceding
ones.

The annual address, delivered before the Society, by its President, Dr. R.
La Roche, at its session of May, 1857, is among the most able and interest-
ing of the large number of productions of the same class, we have had an
opportunity, for several years past, of perusing. It is replete with import-
ant truths that cannot be too often brought to the notice of the members
of our profession, or too strongly urged upon their attention. Could the
public in general be brought to a full recognition of the leading principles
adduced and ably enforced by Dr. La Roche, it would be equally to their
advantage as to that of the well instructed, skilful, and honourable members
of the medical corps ; for scarcely less interested is each individual of the
State in the elevation of the professional and moral standing of the medical
profession, and the accurate definement and proper protection of its legitimate
rights, than are its own members; inasmuch as all must necessarily derive
from the enlargement of medical science and skill, through the labours of an
educated, experienced, and faithful body of physicians, recognized and che-
rished by enlightened public opinion, increased security from the causes of
disease, on the one hand, and on the other, a greater certainty of prompt and
entire recovery from its attacks.

Dr. La Roche commences his address by a striking and faithful delineation
of the importance to the profession of a complete and efficient organization of
its members in each locality, county, and State, fie points to the well-recog-
nized fact that from associated action among those engaged in the same pur-
suits, far greater advantages are to be obtained, and more important results
with certainty secured, than can possibly be anticipated from individual efforts,
however energetic and multiplied, and whatever may be the professional and
social standing of those by whom such efforts are made. The divided action
of the largest number of intelligent and well-instructed physicians, spread over
the broad surface of the State, can never accomplish the same amount of per-
manent good to the profession generally, as is certainly to be obtained when
they act in concert and for one common object. The isolated actors lack " the
vivifying influence of emulation, the stimulus to exertion springing from the
co-operation or collective action of many minds equally interested in the at-
tainment of a desired end; they miss the opportunities of improvement flowing
naturally from the interchange of thought, and personal intercourse with such
of their brethren as enjoy ampler means of acquiring a full knowledge on all,
or some special branches of medical science, not less than on the condition and
wants of the profession, or who, from their fields of observation being more or
less remote from each other, are enabled to see facts under the diversified
aspects they are too apt to present." In a word, they eventually fail in secur-
ing that amount of good at which they aim, by endeavouring to work it out
No. LXVIIL-Oct. 1857. 30

450

Bibliographical Notices.

[Oct.

alone, and for themselves, irrespective of the common interests of all who are
engaged in the same pursuits.

From medical organization "other benefits than those having reference to
the general bearing and conduct of medical men living within the sphere of
their jurisdiction are looked for. As already pointed out, such associations
tend in various ways to elevate the character, honour, and dignity of the medi-
cal profession. It is not enough, in order to attain this desired object, that
laws and regulations for the proper guidance of their respective members
should be enacted and enforced through means of the connected action of pro-
perly constituted bodies. It is not enough that, by such bodies, all irregulari-
ties occurring in the professional and social bearing and conduct of such mem-
bers should be corrected, and the repetition of them prevented, and that the
requisite means to remedy the evil accruing therefrom should be indicated. A
certain degree of influence, both direct and indirect, must be brought to bear
on those members individually, with a view to stimulate their zeal and ener-
gies to the vigorous pursuit of inquiries of an intellectual character. They
must be roused from the state of mental inertia in which, generally speaking,
men are apt to fall, when deprived of external stimulus. They must be saved
from that condition of stagnation which, 'in the moral, as in the physical
world, generates corruption/ Again, they must be made sensible of the im-
portance of collecting and arranging systematically, useful facts of a patholo-
gical, etiological, and therapeutical kind, and of communicating these, and the
deductions drawn from them, through some channel or other, to the medical
community at large."

Dr. La Roche urges with great force the necessity of a complete classical and
scientific and professional education in all who would enter upon the high and
responsible duties of a physician ; and of continued, uninterrupted study sub-
sequent to their entrance, to render them familiar with the vast store of facts
and principles contributed by those who, in times past, have investigated with
success the several branches of medical science, or which are now being con-
tributed as important additions to the common stock of professional know-
ledge.

" What are called plain and simple practitioners — men who contemptuously
look down on the industrious student, and place him in the same category with
sheer bibliomaniacs ; who ignore book-learning, and stigmatize as useless theo-
rists, all physicians disposed to attach importance to an inquiry into the causa-
tion, nature, and relationship of pathological facts; who affect to rely exclu-
sively upon bedside experience, or what they characterize as simple observa-
tion ; who care little for the results of the experience of their predecessors or
contemporaries ; smiling at the idea of the necessity of comparing the pheno-
mena they observe, and the therapeutic results they obtain with those that fall
under the cognizance of their fellow practitioners, and greatly doubting the
utility of pathological anatomy and other kindred branches of medical know-
ledge ; such physicians, I say, are not, as a rule, the instruments employed by
Providence to promote the progress of medical science, elevate the character
and secure the dignity of the profession.

"They may succeed, and have, doubtless, often succeeded, here and else-
where, in becoming safe practitioners. They may learn to manage in a satis-
factory manner certain classes of stereotype cases of morbid derangements,
which they daily encounter. They may in that way succeed, ultimately, in
becoming useful to those who honour them with their confidence, and also, not
a little to their private interest — eliciting the applause, and commanding even
the admiration of a large portion of the community, who, in total ignorance of
the true requirements of a physician, sing the praise of simple and unsophis-
ticated experience, and deny the necessity of theory, which they stupidly con-
found with hypothesis, while they regard in the light of useless and dangerous
dreamers, all who aim at something beyond the standard they have fixed upon
as the essential qualifications of a medical practitioner. They may do all that,
but I hesitate not to say, that he who looks to them for aid in furthering the
progress of medical science in any of its multifarious departments, will be very
much deceived. Even practical medicine, on their skill in which they pride

1857.]

Transactions of State Medical Societies.

451

themselves, receives but slender benefits at their hands. Physicians of that
class are at a loss whenever they encounter cases such as they had not seen
before. Even the less usual modifications of ordinary complaints, are but too
often to them a source of embarrassment — not unfrequently a rock on which
they founder. Or, if, through means of an unusual degree of native sagacity
and medical tact, or a constant habit of the sick room, they succeed, at last, in
surmounting some of these difficulties, certain it is, the number of such fortu-
nate physicians is exceedingly limited, and whatsoever be their success, they
teach nothing to their own, and particularly to future generations. They never
prove benefactors to science. The latter, in their hands, never advances beyond
the point at which they found it. Indeed, I am not sure that, if left to their
fostering care alone, it would not retrograde. Medicine, with the greater num-
ber of such routine and empirical physicians, is not a science. It is not even
an art. It is a trade. Content with finding a remedy for the disease for which
they are called upon to prescribe, or for some particular phenomenon ; employ-
ing this remedy because they think it has been useful in some instances of like
kind, they ignore principles ; or if they raise the pretension of being guided
by pathological views, it is ten to one that such views are not founded on sound
principles, and are calculated to excite a smile from all well-informed physi-
cians."

" Nothing, it has always appeared to me, is more devoid of force — I had almost
said, more senseless — than the opposition that is so often made to what is sneer-
ingly denominated book-learning, and the reason assigned to justify that opposi-
tion— i. e., that a physician who spends much time in reading ; who is learned in
books, and especially who cultivates general literature, cannot, on that account,
become an experienced and successful practitioner. Doubtless, as said before,
an exclusive devotion to information derived through such means, and a neg-
lect of that furnished by an assiduous attendance at the bedside of the sick,
would lead a physician to results of a doubtful character. But, because such
a mode of proceeding would never enable him to acquire the clinical experience
requisite to render him useful in a practical point of view, it does not follow,
as is but too often asserted by some physicians, and is still more generally
echoed by the public, that a reading physician cannot become skilful and
successful in the practice of his art. So far from this, when restricted within
reasonable bounds, and combined, as it should, and may easily be, with clinical
knowledge, that*much abused book learning generally proves of the most
decided advantage to the practical physician, and places him in a much higher
position in respect to his usefulness as an attendant at the bedside. The history
of our profession furnishes us with numerous cases in illustration of the truth
of this statement, for we therein find, that among the greatest practitioners
and clinical teachers whose names adorn its pages, a large number were well
and even deeply versed in the literature of the science — many in general litera-
ture ; while not a few of those who from want of time or inclination, had neg-
lected to store their minds with information derived in the way mentioned,
would evidently have avoided many errors, and risen higher than they have
done in the estimation of their contemporaries and successors, had they followed
a different course. A well read physician has more resources at his command
when placed at the bedside of the sick. Knowing what has been observed and
done by others, as regards the treatment of diseases which fall under his obser-
vation, as well in their pure as in their complicated states ; aware also of the
results of the researches made in various places, and under diversified circum-
stances, by individuals competent to the task, relative to the nature and seat
of those diseases — the symptoms by which they can be detected, the signs by
which they may be diagnosed, the treatment and organic changes they occasion,
or which reveal their true nature — he is better prepared to combat them with
success, whatever be the modifications under which they present themselves,
and, instead of groping as it were in the dark, resort to the means found useful
in the management of cases similar to those before him, but which he may not
have already seen in their present aspect. He is more certain to arrive at a
correct diagnosis and prognosis even in cases, or modifications of cases, of un_
usual occurrence. He is less apt to find himself at a loss in moments of emer.

452

Bibliographical Notices.

[Oct.

gency, and more adequate to take an enlarged and correct view of the causation
and nature of the diseases under his charge, and to deduce from his observa-
tions principles calculated to guide him successfully in the selection of his
medical means. To this let me add, that a physician of the class under con-
sideration, is less in danger of merging into the mere empiric, or of lapsing
into quackery than the indiscriminate condemner of book learning. The latter
contribute little or nothing to the progress of even practical medicine. They
live, they die, they are forgotten. At the time of their disappearance from the
stage of life, the amount of practical resources at their command is scarcely
greater than it was when it commenced, except as is afforded by a certain
degree of familiarity with the salient phenomena and the progression of dis-
eases commonly encountered by them during their rounds, and with the effect
in the treatment of these, of common remedies. They leave nothing likely
to benefit others. They are besides seldom fastidious in regard to professional
ethics, and are not in general looked up to as beacons for the guidance of their
brethren in their endeavours to elevate the medical profession in the estimation
of the public at large."

Dr. La Roche enforces with great truth the necessity of a certain amount of
enthusiasm, as a necessary element of success in the physician who would per-
form well his duties to those placed under his professional care, and contribute
effectually towards the advancement of medicine as a science and an art. In
the conclusion of his remarks on this subject, he says : —

"I have said enough to indicate my belief that a physician cannot hope, and
is not destined to attain, the object in view, still less to acquire an eminent
position among his brethren, and contribute to the advancement of any one of
the several branches of the science he cultivates, unless he be endowed with
the love or enthusiasm of science, and enters into the pursuit of the knowledge
necessary to the proper performance of his professional duties with more than
a common alacrity. Open the records of the profession, and task your memories
respecting the physicians you have heard or read of, or whom you are now
personalty acquainted with, and you will agree with me in the opinion that all
who have contributed to the results mentioned ; all who are, or deserve to be
numbered among the ornaments of our profession, who have obtained a high
position among their compeers on the score of their attainments as physi-
ologists, pathologists, anatomists, chemists, botanists, &c, were, or are endowed
with a greater or less share of the enthusiasm in question. Even those who have
pursued with success the department of clinical medicine, and who usually are
regarded by the public at large, and a certain class of practitioners, as the
beau-ideal of physicians, and as belonging to the only useful class of medical
men, on the score of being, as it is thought, more practical than theoretical in
their tendencies — even they have reached their eminence in the ranks of the
profession through the influential agency of enthusiasm. For medical observation
is not simply the result of a passive operation of the organs of sense. It re-
quires, in order to lead to useful issues, a force of mind, a quickness of perception,
a degree of penetration, and hence efforts of the intellectual functions — a con-
stant and rapid appeal to the faculties of causation and comparison, which
cannot be exercised to the required point unless under the stimulus of enthusi-
astic excitement. Had he not been under the control of the agitating and
impulsive feeling in question, Hippocrates would not have been remembered in
after times. Nor would Galen, Celsus, Avicenna, nor Boerhaave, Harvey,
Stoll, Selle, Cullen, J. Hunter, Broussais, Louis (I mean he of Surgery), nor
Bichat, Rush, Tommasini, and a thousand others I could mention. None of
these, I repeat, could have attained the eminence they occupy, and stamped
their names in imperishable letters on the pages of our professional history,
had they not felt the vivifying effects of the sacred fire in question."

The comments of Dr. La Roche on the subject of medical education as it is
conducted in this country are sound and pertinent.

The following are a portion of the very just though severe remarks in the
address before us, on the subject of American medical literature : —

" It is said that the character of a nation may be ascertained from the nature
of its literature. With equal propriety we may affirm that the position, honour,

1857.]

Transactions of State Medical Societies.

453

and dignity of a profession may be estimated by the same standard. If sub-
mitted to this criterion, we are compelled to admit that the reputation of the
medical profession in this country will not stand the ordeal ; for we discern
nothing in our literature, viewed in its totality, calculated to shed lustre on our
calling — much, on the contrary, to affect injuriously its honour, and position,
and lessen its dignity. I have said, in its totality, for in several of its depart-
ments that literature, though in its infancy, when compared with that of
Europe, has attained a degree of eminenee of which every American physician
may justly be proud. My remarks apply more especially to the periodic
medical press, in which, if we except some journals and reviews, that would
do honour to the literature of any country, and are fit representatives and
supporters of the character and respectability of the profession, are exhibited
an absence of solid knowledge, a jejuneness, a lack of useful materials, a
prolixity about things perfectly unimportant — which everybody knows, and
often for which nobody cares — and very generally a deficiency of refinement,
good breeding, and literary culture, little calculated to aid in raising us in the
estimation of the scientific world, and in promoting the attainment of the
desirable object to whi%h allusion has so often been made. Every place must
have its journal — sometimes more than one ; every physician thinks himself
qualified to edit a journal. It not unfrequently happens that he has never
seen or treasured up in his recollection anything worth communicating, and
that he has no one around him competent to aid him in the undertaking. As
frequently it occurs that he is located in a position where facts of a novel,
important, or interesting character are never encountered ; or when so, are at
best not sufficiently numerous to furnish food for more than a short annual com-
munication. As often his pursuits have not been, and the appliances within
his reach are not such as to enable him to carry on pathological, therapeutical,
or other investigations in the way best calculated to render them truly useful
and acceptable to medical inquirers. It may happen, also, that he, no more
than his colleagues, if he has any, is an adept in the art of composition, and
that he is deficient as regards the simplest elements of a correct and polished
style. It is not unusual, besides, to find that he, for the most part, limits his
reading to a few text-books and sundry journals of a merit equal to that of his
own bantling, and that in point of tone, taste, and discretion, he can lay but
slender claim to the approbation of cultivated minds. But no matter — his
place must have a journal, and he must be the editor. He is full of an idea
of his importance, and blind to his many disqualifications to perform with
proper efficiency the duties he has undertaken. So, his production is launched
forth into the literary world to the no small injury of the entire profession, of
whose intellectual and scientific position, no less than of its honour and dignity,
it is but too apt to be viewed by the medical critics and readers of Europe, as
by a large portion of the public here, as a fitting exponent.

"We could, of course, scarcely expect to find, in such journals, judicious,
well written monographs on important medical topics, or a detail of interest-
ing cases establishing their true pathological character or therapeutical indica-
tions, or other communications, exhibiting a correct knowledge of the subject
matter. Equally futile would it be to search therein for fair, elaborate, and
learned reviews of recent publications, temperate and courteous in tone, how-
ever severe in criticism. But while such things cannot well be looked for in
the kind of journals here referred to, we might expect that the better sort of
periodical publications, and especially those of a high order, published in cities
of some literary pretension, would escape the charge of being, occasionally,
at least, receptacles of essays, and especially of reviews, of an indifferent and
otherwise objectionable kind. This, however, I regret to say, is not the case,
for instances might easily be pointed out in which the pages of those journals
have been disfigured with trite, unmeaning, childish, so-called original articles,
and with bibliographical notices and reviews, in which American and other
works of merit and importance are mentioned in the most flippant and trifling
manner, or dismissed with a few words or lines suited rather for a publisher's
advertising sheet than the pages of a scientific journal ; or, what is worse, in
which the authors noticed are treated most unfairly and uncourteously — repre-

454

Bibliographical Notices.

[Oct.

sented sometimes as saying the reverse of what they have really said — turned
into ridicule on points of doctrine or practice on which the reviewer happens,
ten to one, wrongfully, to differ with them — taxed roundly and unceremoniously
with want of experience or knowledge of the subject under consideration, and
not unfrequently charged with falsehood and insolence for uttering sentiments
unpalatable to a certain clique or favourite writer, or a popular teacher."

We regret that we cannot, without encroaching upon the space destined for
other articles that claim admittance in the present number of the Journal, in-
dulge in any extended quotations from that portion of Dr. La Roche's address
in which, with merited severity, he scourges the rampant quackery with which,
under multifarious forms, every portion of our country is overrun and disgraced.
We can venture only a single sentence, the bitter satire of which is but too well
merited: —

" Boileau tells us of an individual who • de mauvais medecin devint pire archi-
tect.' In our beloved country, we often see bad shoemakers, or the like, becom-
ing worse doctors. In the former case, the charge was nothing but an un-
founded sarcasm ; for the bad physician who, according to the French satirist,
became a worse architect, was no less a personage than Perrault, and he, what-
ever may have been his medical deficiencies, will certainly be admitted to have
exhibited no slender claim to respect in his new avocation, seeing that he em-
bellished Paris with the magnificent fagade of the Louvre. But had the charge
of degeneration been well founded, there would have been this difference between
his case and what happens among us: that the bad architect would have ob-
tained no employment in his new line of business — certainly would not have
worked on the Louvre ; whereas, our bad shoemakers, who become worse doc-
tors, command the confidence of the public, and generally reap a rich harvest."

The first of the reports is one on vaccination and vaccine virus, by Dr. Henry
Carpenter, of Lancaster. There are many questions connected with the sub-
ject of vaccination of deep interest to the physician, and in the correct settle-
ment of which the safety of the community at large, from the introduction of
smallpox in its midst, and its more or less extended spread, is intimately in-
volved. These questions are rather indicated than discussed in the report before
us.

To render vaccination a certain prophylactic to the variolous contagion, it is
necessary not merely that each individual in the community should, at as early
a period as practicable after birth, be subjected to its influence, but, also, that
the utmost care be taken, in each case, to place the system fully, effectually,
and permanently, under its protective influence. Now, to effect this, it is essen-
tial that none but genuine, efficient matter should ever be employed in vacci-
nating; that the insertion of the matter be carefully and properly performed;
and that the progress of the arm from the period when the matter is introduced
into it to the full development of a genuine vesicle, its maturation and desicca-
tion, be attentively watched by one competent to decide as to the genuineness
and completeness of the infection. Many circumstances may occur, even after
a true vaccine vesicle has been developed, to prevent that complete infection of
the system being secured, from which alone entire protection can be anticipated.
The evil resulting from an imperfect or spurious vaccination, does not stop with
the endangering of the life of the patient in whose case it happens, but it endan-
gers, through the susceptibility of such patient to subsequent variolous infec-
tion, the introduction of smallpox into a community, and the lives of all such
of its members as are still unprotected. It furthermore impairs the confidence
of the community in the value of vaccination, which of itself is an evil of no
slight magnitude.

Now, to insure the success of vaccination as a complete and permanent pro-
tective against smallnox, it is essential that in every case pure, efficient, and
genuine vaccine virus be employed. That there is in common use vaccine
matter which has become to a certain extent deteriorated or effete, and which,
in consequence, affords, when introduced into the system, only a partial or tem-
porary protection, is undeniable. The fact is admitted by physicians of expe-
rience and close observation, in every section of our country, and the conse-
quent necessity for the adoption of the proper means for securing a renewed

1857.]

Transactions of State Medical Societies.

455

supply, at proper intervals, of genuine, effective matter has recently been
largely discussed. To secure such supply, we know of no other certain plan
than a resort to the original source of the vaccine virus — the cow. We are
convinced, from the successful efforts we have ourselves made, that by the
agency of such of our county medical societies, as are located in the immedi-
ate neighbourhood of extensive grazing and dairy districts, pure vaccine mat-
ter direct from the cow, could be collected with but little trouble or expense, in
quantities fully adequate to the supply of all the physicians of the State, and
that a plan could be devised for the proper and regular distribution of the mat-
ter thus obtained/at once simple and efficient. Upon the societies referred to
we would urge a consideration of this subject; we trust that they may be in-
duced to take it in hand without delay. By carrying it into effect they would
secure the thanks of the profession throughout the State, while for whatever
trouble and expense they may incur in its effectual prosecution they may be
adequately remunerated by a trifling charge on the different portions of matter
distributed by them.

We do not pretend to assert that vaccine matter degenerates in activity and
efficiency in proportion to the number of human bodies through which it is
made to pass. We have repeatedly seen the most prompt and genuine infec-
tion produced by matter that had been propagated through the human subject
for a long series of years. But this we do assert, that the longer vaccine mat-
ter is thus propagated the greater is the chance, from a great variety of causes,
some unavoidable, and others the result of carelessness and ignorance — of its
becoming deteriorated and inefficient, and that the only certain mean3 of keep-
ing up a supply of genuine, effective vaccine matter, is by renewing it occasion-
ally at its original source.

It may not be improper to remark, that even universal and apparently effi-
cient vaccination, .performed with unquestionably pure, genuine, and active
matter, will fail in securing the community against the occurrence of smallpox,
in a modified form at least, unless each individual vaccinated be subjected to
the test of revaccination. It is a fact, now well attested by the most extensive
and repeated series of observations, that there exists a wide difference in the
constitutional susceptibility, not merely to the infection of the vaccine virus,
but also to that peculiar constitutional influence or change by which its influ-
ence is rendered permanent. In many subjects the effects of the vaccine im-
pression would appear to be entirely local, while in others, notwithstanding
the impression evidently extends to the system at large, this general impres-
sion is either not sufficiently intense to give complete protection, or it is, after
a shorter or longer period, entirely dissipated, and thus leaves the system
fully susceptible to the contagion of smallpox, when exposed to its influence.
The importance, or rather the absolute necessity of revaccination as a test of
the completeness ancl permanency of the first infection is therefore apparent.
How soon after the first vaccination, the second operation should be performed,
or how often it is necessary to resort to revaccination, are questions we do not
propose to discuss here. Until a system of registration in respect to vaccina-
tions, accessible to the medical profession at large, shall be agreed upon, and
carried into full effect, by which we shall be enabled to judge of the validity of
the operation in each case, our course would be to revaccinate, without distinc-
tion, all who are exposed to variolous contagion, either from the occurrence of
smallpox in their immediate neighbourhood, or as an epidemic in the commu-
nity amid which they reside.

The Transactions of the Pennsylvania State Society comprise reports from
nine counties. These reports vary greatly in extent and interest. There is
none of them, we regret to say, that can claim any very high character for the
ability with which it is drawn up or the value of the information it communi-
cates. So far as we are able to form from these reports any judgment of the
general health of the State during the year 1856, this would appear, upon the
whole, to have been particularly favourable. There was a general absence of
severe, malignant, or wide-spread epidemics, and even the usual endemic dis-
eases of the several sections of the State included in the reports presented were
of much less frequent occurrence and far milder in character than ordinary.

456

Bibliographical Notices.

[Oct.

The report from Chester County is preceded by a very valuable account of
the geology, the medical topography, and the meteorology of the county; the
one from Washington County presents a similar account, of great interest, but
less full and precise.

To several of these reports are appended biographical notices of members
deceased during the year, a practice that we should like to see more uniformly
followed.

In the report from Beaver County we find the following remarks in reference
to the occurrence of an epidemic of dysentery: —

" In 1834, a year remarkable for a very extraordinary severe frost, which
fell so late in the season that all the fruit of every kind was killed, not even
any of the wild fruits escaping — in many places, on the low grounds, the forest
timber was much injured by the frost — dysentery prevailed in the months of
July, August, and September, in a manner unknown either before or since,
both as regards its malignancy and the extent of country over which it spread.
It was much worse, however, on the south side of the Ohio River. A creek of
considerable size (Raccoon) passes through the entire county on the south side,
emptying into the river about three miles below Beaver. Along this stream,
in the bottom and on the immediate hill-sides, there was not a family that
escaped this disease. It frequently ran through all the family.

" In relation to this epidemic, the most interesting inquiry is its cause. "What
was the cause ? The section of the country where it prevailed in its most ma-
lignant form remains unchanged, wearing the same general appearance it did
twenty-three years ago. There have been no improvements that could possibly
affect the health, no ground of any consequence cleared. Notwithstanding
that nearly twenty-three years have rolled round, with all the diversity of sea-
sons occurring in that long period, yet that district has been entirely exempt
from dysentery ; scarcely in all this time has an isolated ease occurred. The
immoderate use of unripe fruit is very frequently assigned as the cause of this
disease. As there was no fruit of any kind in 1834, it could not, of course, be
attributed to it. Is it not probable that this total want of fruit was one cause
of the disease, its place being supplied by the crude, immature products of the
garden and field? It is not at all probable that fruit, used even in excess, is
the cause of dysentery." " The universal fondness that all children have for
fruit would seem to indicate that it is necessary for their health. Our natural
healthy instincts are never wrong."

In the report from Perry County, Dr. Lefever states that he was informed by
a gentleman of his acquaintance, but not of the medical profession, " that he
had been in different parts of our country where dysentery prevailed as an
epidemic, and during some seasons many of the cases terminated fatally ; and
in every instance he had observed that fruits were very scarce in the particular
section of country in which the dysentery prevailed. From this fact he was
led to believe that, instead of being the cause of dysenteric affections, an abun-
dance of fruit was a preventive of such diseases. From my own observations,
I am not able to express an opinion as to the probable truth of the position
mentioned ; but I am inclined to believe that even the free use of good, ripe
fruits will rarely prove injurious, and might oftentimes be permitted to those
who are unwell, where physicians are in the habit of forbidding it, because
such has been the custom. Where patients desire it, I have frequently allowed
ripe fruits in moderation in cases of disease, and very seldom, indeed, have I
had any reason whatever to believe that the slightest injury resulted from the
license given ; but, on the other hand, I believe I have frequently seen good
results follow."

Returning to the report from Beaver County, we are informed that "epidemic
cerebro-spinal meningitis prevailed there in the spring of 1848, in a very ma-
lignant form. The attacks were mostly sudden. The patient would be seized
with violent pain in the head, most severe in the occiput, but frequently being
felt in the temples and over one or both eyes ; the pupils of the eyes were
mostly contracted, but sometimes dilated ; great intolerance of light ; the brows
knit ; throbbing of the carotids ; severe pain in the back of the neck and along
the spine ; in many cases violent opisthotonos ; during the paroxysm the body

1857.]

Transactions of State Medical Societies.

457

would be raised entirely from the bed, the head and heels alone touching ; de-
lirium and coma in the advanced stages ; obstinate constipation of the bowels,
it being with great difficulty that evacuations could be produced; the functions
of the kidneys were partially or totally suspended. Many cases proved fatal
very speedily, whilst others would linger until the patient would become ex-
tremely emaciated ; in the latter cases there would frequently be a total loss of
sight and most of the other senses. We are not aware that any post-mortem
examinations were made, the people in the country being greatly opposed to
anything of the kind."

In the report from Blair County it is remarked that "intermittent fever and
ague were hardly known along the Juniata this year. During the preceding
year (1855) seven-tenths of the residents of the river valley had intermitting
fever or ague, or both; while, at the same time, in Franktown Township, it
extended up the small tributaries of that river for several miles, into localities
where it had never before penetrated, spreading dismay among those unac-
quainted with it. That whole summer the channels of the river and its tribu-
taries were kept well filled by frequent rains. On the contrary, the summer of
1856 was very dry, the streams very much dried out; so that a large surface
of their channels, with whatever of vegetable or animal matter they contained,
was exposed to decomposition. Why in 1855, when all the conditions were
those considered unfavourable for the extrication of malaria, intermittents
should be so extremely rife, while in 1856, when the conditions seemed altogether
favourable to the production of malaria, those diseases should scarcely exist, is
a question somewhat knotty of solution."

Dr. George W. Brown, in the section of the report from Schuylkill County
devoted to the consideration of the diseases of women and children, tells us
that when he left college he was fully satisfied, from having listened to Pro-
fessor Meigs's very emphatic assertions in regard to the treatment of puerperal
fever, that he ought to bleed every lying-in patient that was seized with a
shivering fit, followed by pain in the belly, and fever, without regard to her
constitution, and he did so till he nearly lost several of his patients by syncope,
and produced long and tedious convalescence in others, when he began to doubt
its indiscriminate applicability ; since then he has come gradually to use his
own judgment, and has bled only such cases as were strong and vigorous, and
when the symptoms were clearly of an inflammatory character, and trusted the
others to the internal use of calomel, opium, pulvis antimonialis, and oil of
turpentine, and he thinks he has abundant reason to be satisfied. After an
experience of thirteen years, and an attendance upon nearly two thousand cases
of midwifery, in a pure, invigorating atmosphere, among a class of patients who,
as a general rule, are well fed, and from a pretty ample attendance upon cases
of childbed fever, he is satisfied that it, like all other diseases, is of two kinds,
viz., inflammatory and typhoid, and that these require essentially a different
treatment. He is also perfectly satisfied that the disease is at times contagious,
and that the physician is oftentimes the unsuspecting medium by which it is
conveyed from patient to patient. He is fully satisfied that he has several times
introduced it into his practice by attendance upon bad cases of erysipelas, and
thinks he has often got rid of it by carrying in his pocket a bottle of Labar-
raque's solution of the chloride of soda, and washing his hands with it each
time before and after an examination of his patients.

In the report from Montgomery County, Dr. Corson complains of the paucity
of details presented in the several county reports in reference to the treatment
of the diseases ordinarily met with, whether in its results it was found success-
ful or otherwise. To a certain extent we admit that the complaint is well
founded.

With a view to obtain information on this point, a series of questions were
propounded to the different members of the Montgomery County Society, which,
with the answers received, are given in the report before us. Now, in reference
to information obtained by replies to such general questions as — Do you bleed
in fevers and inflammations? What is your treatment in this or that disease?
Do you prescribe mercurials in any disease? Do you employ alcoholic stimu-
lants in typhoid fever or other affections? and the like, one or two important

458

Bibliographical Notices.

[Oct.

cautions must be observed. Before any safe conclusions can be derived from
the answers given, it is essential that these should not be simply in the affirm-
ative or negative, even if they at the same time present the result of treatment,
whether favourable or unfavourable ; the answers must, in order to be of any
value, include also an account of the particular character of the disease in each
case prescribed for ; the age, sex, constitution, occupation, and personal habits
of the patient ; the character of the location in which he resides, and the con-
struction, position, and domestic condition of the house he occupies ; and, even
further still, the morbific constitution of the season during which each case
occurred.

The prevailing error in reference to special therapeutics is the supposition
that there is an invariable treatment, a particular class and succession of reme-
dies, adapted to each disease; that the name of a disease being determined, the
nature of the exact means adapted for its cure follows as a matter of course.
The fact that a certain physician, in a certain place, cured nine-tenths of the
patients affected with any given malady with the use or without the use of de-
pletion, mercury, or stimulants, is no safe basis upon which to determine the
propriety and success of a similar course of treatment in the same disease in
a subsequent year or at a different locality, or in a different class of patients.

The precise therapeutic effects of all our remedial agents being well esta-
blished by cautious and repeated observations, they are to be applied to the
control of disease according to the special indications presented by each indi-
vidual case. It is in this application — it is in the judicious use of the remedies
at his command best adapted to the control of each case of disease that presents
itself, in connection with his facility in arriving at a prompt and accurate diag-
nosis, that the true skill of the practitioner is exhibited. The physician who
tells us that he treats this or that disease by such and such remedies is at best
a mere routinist, and his experience is valueless as a guide to direct others to
the successful treatment of the same malady as it presents itself in a different
class of patients, at a different season, or in a different section of country.

D. K. C.

Art. XVIII. — Catalogue BaisonnS of the Medical Library of the Pennsylvania
Hospital. By Emil Fischer, M. D. Printed by order of the Board of
Managers. 8vo. pp. 750. Philadelphia, 1857.

In the year 1762, the celebrated Dr. John Fothergill presented to the Penn-
sylvania Hospital Lewis's Experimental History of the Materia Medica, " for the
benefit," as the record says, " of the young students in physic who may attend
under the directions of the physicians." Upon this hint, the managers acted,
for we find them in the following year originating the library, the catalogue of
which is now before us.

Even at this early period, the hospital, under the teaching of such men as
the two Bonds (Thomas and Phineas), Thomas Cadwalader, and Cadwalader
Evans, had become famous for its clinical instruction, and the wards of the
house were so largely attended that the managers thought it necessary to
demand an admission fee.

According to the then custom of British hospitals, all funds thus accruing
belonged exclusively to the attending physicians and surgeons ; these gentle-
men, however, with a noble generosity, yielded all claim to the money, and
proposed to apply it " to the foundation of a medical library for the advantage
of the pupils of the Institution." Truly, we should remember these men of
old with grateful remembrance. They were men not of the common stamp,
endowed with all the medical learning of their time, and with a Christian
philanthropy never surpassed, they stand out in bold relief as models for
imitation. To them and to their immediate successors, Philadelphia owes the
high position to which she has attained in the medical history of our country.
They made her, as has been happily said, "the very atmosphere of medicine."

1857.] Fischer, Catalogue of Library of Pennsylvania Hospital. 459

For years after their departure, our medical institutions felt the impress of
their character, and it might be readily shown that, in proportion as these have
departed from their high standard, just in that proportion have they suffered in
reputation and standing. What has been so eloquently said of others, may
with greater force be said of them. " They have passed away and we have
entered into their labours. But, though dead, they yet speak to us in that
which they have left us. They speak to us in the noble reputation thay have
acquired for our institutions, and which we are bound to maintain. They
speak to us in the ardent zeal of their pursuit after truth, which they call
upon us to imitate, and again they speak to us in the individual celebrity
which they acquired, and encourage us to similar attainments. Let us then
bow low at the mention of their names, and bless God for giving us such an
ancestry."

The library thus founded increased by liberal donations and judicious pur-
chases, made chiefly by Dr. Lettsom, of London, with great rapidity.

The first catalogue was printed in 1790, when the number of books was 528
volumes. This was followed, in 1794, by an additional part. A catalogue
was again issued in 1806, to which was added a supplement in 1818. In 1827,
in consequence of the very large accession of books to the library, another
edition of the catalogue was considered necessary. This was compiled by W.
G. Malin, then librarian (now the very able and efficient steward of the Insti-
tution), and embraced all the previous catalogues. A supplement followed
this in 1837, the library then numbering 7,300 volumes. Since that time, the
average number of books yearly added to the collection has been 160, so that
it contains at present 10,500 volumes.

Thus it is seen how, by judicious management, has been gathered around a
single volume — the gift of Fothergill, the largest and best collection of medical
books in the United States — a library worthy of the medical metropolis of the
Union, and no unfit monument to the memory of the great and good men, its
founders.

After this short and imperfect account of the origin and present state of the
library, we shall allow Dr. Fischer to introduce his volume to our readers in
his own words. " The present catalogue is an entirely new work, and has
been compiled independently of its predecessors. For the old plan of dispos-
ing the works in the alphabetical order of the names of their authors a classi-
fied arrangement according to subjects has been substituted. The advantages
of a catalogue raisonne are so evident that it is hardly necessary to particular-
ize them. Not only the student who is anxious to familiarize himself with the
depth and breadth of medical literature, but also the medical writer in his
laborious research for authorities which he might consult on the subject of his
investigation, will derive material aid from a work of this kind."

The arrangement adopted is that of the catalogue of the Koyal Medical
Society of Edinburgh, which was published in 1837, the year in which the
Society reached its centenary period.

In selecting this as his model, Dr. Fischer did well, for undoubtedly it is the
best "digested" or "methodized" catalogue ever published. It is not, how-
ever, a catalogue raisonne, and we regret that the Dr. has retained its very
objectionable title. A catalogue raisonne^ properly so called, is one which
gives under each book, worthy of such a note, a bibliographical, critical, and
literary notice of the volume. Without doubt, it is the best plan for the col-
lection of an amateur, but is altogether too bulky for a large public library.

In support of what we say, we may refer to Ch. Nodier's Noveaux Melanges,
Paris, 1844. This is a catalogue raisonne of some 1200 volumes, yet it forms a
goodly sized 8vo. vol. of 500 pages. At this rate, our volume would have
reached about 4375 pages.

Should any of our readers feel disposed to look into the different systems
which have been devised for catalogue-making, we cannot do better than refer
them to Gabriel Peignot's Dictionnaire de Bibliologie, 3 vols., Paris, 1802-4, where
they will find the subject discussed with all the gusto of a true bibliomane, and
where they may learn this, if nothing else, that it takes something more than,
a mere scrivener to draw up a good catalogue.

460

Bibliographical Notices.

[Oct.

We shall now say a few words on the volume before us. Following his
model, Dr. Fischer divides his catalogue into four parts ; the first relating to
works on medicine ; the second to those on science, including physics and
chemistry, natural history and psychology ; the third to those on general lite-
rature ; and the fourth to miscellaneous works not referable to any of the pre-
ceding heads, and the journals, reviews, and other periodical publications ;
then comes a very full and complete index of the names of authors.

The department in which we are most concerned — that of medicine — is sub-
divided into chapters in the following manner : Anatomy, Human and Com-
parative ; Physiology ; Materia Medica and Pharmacy, including Hygiene and
Therapeutics ; General Pathology and Practice of Physic ; Surgery ; Midwifery
and Diseases of Women and Children ; Medical Jurisprudence and Medical
Police ; and Medical Literature.

Under each of these heads, the respective works are carefully and ably
arranged, exhibiting a very considerable acquaintance with medical literature.
The arrangement is so complete and full that the student can readily put his
hand upon the principal works which he may wish to consult, in order to
enable him to follow up any branch of inquiry. In this respect, the catalogue
is invaluable, not only to the student, but to every member of the profession
who can get access to the library.

"We might further add that the classification and subclassification of the
different chapters coincide, as far as it could be done in a work of this kind,
with those adopted in systematic treatises on the different branches of medical
and general science. Only in those instances where no scientific ground for
classification could be found, the alphabetical arrangement has been had
recourse to.

In going over the catalogue, which we have done with some care, we have
been struck with the small number of German and Italian works on medicine ;
of French and English medical literature, on the contrary, there is an excellent
representation ; and we have to express our regret at meeting with so few of
our own medical journals of the present day. Surely this is a mistake that
should be remedied. Journal-literature should ever form a prominent depart-
ment in all medical libraries ; especially should this be the case in our country,
in consequence of its vast extent and great diversity of climate. Of the older
journals, several of the sets are incomplete ; these should be completed without
delay, as many of them are becoming so scarce that, in a short time, it will be
impossible to do so.

We have thus hastily brought the volume before us to the notice of our
readers. Any recommendation of it would be superfluous. We believe that
its existence can no sooner be known than its great value will be recognized.

To the Board of Managers of the Hospital we are greatly indebted for this
work, and we congratulate them and the profession on the creditable and use-
ful manner in which it has been " gotten up." They were most fortunate in
obtaining the services of one so well calculated as Dr. Fischer to undertake a
work so laborious and difficult. None but those who have been engaged in
such an undertaking can in any way appreciate the enormous labour which it
entails. " Of the time and labour," says Sir John Forbes, speaking of his
Medical Bibliography, " bestowed on the following pages, it may be prudent
not to speak, lest the actual scantiness of the harvest should appear still more
conspicuous in relation to the extent of the workman's toil. We may, how-
ever, venture to say this much, that no one who has not actually made the
trial is likely to form an accurate estimate of either the one or the other."
Dr. Fischer brought to the work all the qualities necessary for a successful
issue — education, scientific knowledge, great perseverance, and withal, a love
of the thing. The result has been that to him belongs the honour of having
compiled the best medical catalogue in the English language. We congratulate
him most sincerely on having performed so severe a task in so able a manner
— a task which few would have had the courage to undertake, and still fewer
the ability to carry through. S. L.

1857.]

American Insane Hospital Reports.

461

Art. XIX. — Reports of American Institutions for the Insane.

1. Of the Maine State Hospital, for the year 1856.

2. Of the Vermont State Asylum, for the f seal year 1855-6.

3. Of the McLean Asylum, for the year 1856.

4. Of the Butler Hospital, for the year 1856.

5. Of the Hartford Retreat, for the fi seal year 1855-6.

6. Of the King's County Asylum, N. T., for the fiscal year 1855-6.

1. Lsr the report from the Maine Insane Hospital, we are informed that
during the year ending on the 30th of November, 1856, " the operations of the
Institution have been highly prosperous and successful. A number of pa-
tients considerably larger than ever before have enjoyed its benefits. No un-
usual sickness has visited the inmates, and no case of suicide or homicide has
occurred."

Patients in the hospital Nov. 30, 1855

Admitted in course of the year .

Whole number . . . .

Discharged, including deaths

Remaining Nov. 30, 1856 .

Of those discharged, there were cured

Died

Men.

Women.

Total.

155

149

171

133

304

114

105

.190

Causes of Heath. — General paralysis 6 ; tubercular consumption 4; maniacal
exhaustion 3 ; marasmus 2 ; peri-pneumonia 1 ; diarrhoea 1 ; serous apoplexy
1 ; epilepsy 1.

" The legislature, at its last session, enacted a law by which the State as-
sumes one dollar per week of the expense of all patients sent to the hospital
who are unable to pay their own bills, and have no relations of sufficient means
liable by law for the same. Eighty-six unfortunate insane persons have en-
joyed the comforts and blessings of the hospital through the provisions of that
law, who (many of them at least) would otherwise never have seen the Insti-
tution, or, having seen and known its comforts, would have been returned to
almshouses — and some, alas ! to cages and chains."

A vast many figures have been wasted in the printing of worthless statistics
of insanity, yet the number is not small of those which have been employed
in the publication of such as are of very considerable value. Some of the most
important and reliable information of this kind which has thus been placed
before the profession, first appeared in the annual reports from the Maine Hos-
pital, when that institution was under the superintendence of Dr. James Bates.
Since Dr. Bates resigned, the tables have gradually left the report until, in the
one now before us, the only figures giving information in regard to the patients
are contained in the following sentence : —

" Since the hospital has been in operation, a period of some sixteen years,
there have been 1,708 patients admitted, and 1,518 discharged. Of the latter,
685 recovered; 298 improved; 323 unimproved; and 212 died."

It is not recollected that Dr. Harlow has expressed any opinion, in either of
his reports, in regard to statistics. The inference from his practice is, not only
that he has no faith in them, as applied to mental disorders, but that, like some
other physicians who are, or who have been employed in the same specialty,
he fully believes in the converse of the proposition, " Figures cannot lie."
Hence, in this report, the numbers admitted, discharged, remaining, &c, are
all printed in words, and not in figures. The information formerly imparted
by tables of civil condition, age, and causes of insanity, is also conveyed in
the same manner; and there the statistical matter stops.

If this method was adopted for the purpose of avoiding errors, by typogra-
phical or other mistakes, it has signally failed, as any one may perceive by an
examination of the subjoined extracts : —

462

Bibliographical Notices.

[Oct.

" We commenced this year with one hundred and fifty-five patients — eighty-
six males and sixty-nine females. There have been admitted, during the year,
one hundred and forty-nine — eighty-five males and sixty-four females, making
a sum total of three hundred and four cases under treatment — one hundred
and seventy-one males, and one hundred and thirty-three females.

"One hundred and fourteen have been discharged from the hospital during
the year — sixty-seven males and forty-seven females ; leaving in the institution,
on the 30th of November, 1856, one hundred and ninety patients — one hundred
and five males, and eighty-five females."

The final clause of the last sentence, to be consistent with all that precedes
it, should read " one hundred and four males and one hundred and six females."
Yet, in converting this information into its representative figures, near the be-
ginning of this notice, we have followed the text. Before leaving this subject
we must remark — and it is done without any special reference to the opinions
or the action of Dr. Harlow — that, of the worthless statistics of insanity, a
large proportion are valueless simply because the labour necessary to render
them valuable has not been bestowed upon them.

2. At the Vermont Asylum for the Insane —

Men. Women. Total.

No. of patients on the 1st of August, 1855 185 209 394

Admitted in the course of the year 80 92 172

Whole number ...... 265 301 566

Discharged 75 84 159

Remaining, August 1, 1856 . . .190 217 407

Of those discharged, there were cured . 82

Died^ ........ 38

Admitted since the opening of the asylum 2,565

Discharged recovered 1,209

Died — not stated.

Dr. Rockwell closes some very appropriate remarks upon the importance of
early treatment, as follows : —

" Although it is very desirable that cases of insanity should be placed in
some proper asylum in the early stages of the disease, still we would caution
those who are interested, not to bring their friends who are afflicted with other
diseases, or before their insanity is fully developed. It is no uncommon cir-
cumstance to have sent us a case in the early stage of delirium, and while
suffering from acute bodily disease. When they reach us they are frequently
too feeble to return to their homes. These cases frequently prove fatal, and
the death, in many instances, is hastened by the exposure and fatigue of the
journey." ,

He illustrates the injurious effects of the premature removal of patients by
the subjoined case : —

" A young married lady had been a few weeks in the asylum, and was ra-
pidly convalescing. When she came she was in a highly excited state, and
her mind was filled with the strangest delusions. She had now become more
calm. The delusions had nearly all faded away, and she began to be conscious
of her situation. But her mind was still in a very weak state, liable to a re-
lapse at any moment, and the greatest caution was necessary to keep from her
all extraneous excitement. At this critical period her husband came to see
her. He was charged with a common idea that there might be something in
his presence that would have a happy influence upon the mind of his wife.
We endeavoured to dissuade him from seeing her, but his mind was fully made
up to take the risk. He found her much better than he expected, and she
seemed better the longer he talked with her. She asked after every member
of the family, and said she was glad he had come for her. His mind was not
made up to take her away just at present, but she talked so well, and had so
clear a recognition of her past situation, that he could not resist the eloquence
of her arguments and appeals, and they went home together. The result was
anticipated by us. Her mind soon gave way under the rush of old associations

1857.]

American Insane Hospital Reports.

463

and new excitements, and she was brought back again in a worse condition
than at first. It will be a long time before she will be so nearly well again,
and it will be fortunate indeed if she is not a confirmed lunatic."

3. The report for 1856 from the McLean Asylum, is the first issued over the
signature of Dr. Chauncey Booth, the successor of Dr. Bell. The long expe-
rience of Dr. Booth in the treatment of the insane, has given him those pro-
fessional qualifications for his post, which are essential to the best fulfilment of

its attendant duties : —

Men. Women. Total.

Patients in the asylum, Jan. 1, 1856 , 88 104 192

Admitted in course of the year 87 62 149

Whole number 175 166 341

Discharged, including deaths ... 81 64 145

Remaining, Dec. 31, 1856 . . . 94 102 196

Of those discharged, there were cured . 36 32 68

Died 10 9 19

Patients admitted from 1818 to Dec. 31, 1856 4115

Discharged, recovered .... 1926

Died 465

Of the moral treatment of the insane Dr. Booth writes as follows : —

" Every one who comes in contact with the insane, in whatever capacity,
whether by his words, manners, or acts, does something to help or to hinder
the success of the moral treatment. * * * This plan of moral agency is pro-
gressive. * * * There is no limit to the application of these means ; and that
institution which fancies it has attained perfection has already begun to retro-
grade. * * * Every day suggests something new."

In reference to the fact that insanity has apparently increased, pari passu
with civilization, he says : " This state of things is not a necessary condition
of true advancement. If the spirit of free inquiry, and the enterprise engen-
dered by our institutions lead to excesses ; if we abuse the power afforded us
by our blessings ; if the intellect is stimulated to its utmost, while the moral
and affectional portion of our nature is neglected ; if, in our haste to secure
immediate results, we sacrifice the greater boon which a thoughtful considera-
tion would have secured ; and if, in all our seekings and searchings, we learn
everything else, but remain ignorant of that higher knowledge, the knowledge
of ourselves, of the laws which are ordained for the government of our physical
and mental organization, we have no right to expect that our civilization will
prove a source of unmixed satisfaction and true progress."

" It is asserted that the insane are more numerous in this country than in
any in Europe. * * * It would seem as if our form of government would be
the most favourable to the best and highest development of our mental and
moral powers ; and yet this pre-eminence may furnish our great danger. Our
system of education, the abundant opportunities for obtaining wealth, and the
ingenuity and rivalry which these call into action, the necessity which is felt
by so many to engage intensely in politics ; the zeal that is manifested in' the
multiplied forms of religious interests, or in the varied objects of philanthropy ;
and the ardor which multitudes exhibit for the divers and ever-shifting isms
and ologies universally prevailing ; all these, and every other phase of mental
effort, tend to excite and produce unhealthy changes in the brain, and thus to
prepare the way for insanity, if they do not actually induce it."

After mentioning some of the defects of education, he remarks : " If this
abandonment of the young to chance, or to influences which cannot fail to
surround them when away from home, continues much longer, the term 'moral
insanity' will cease to raise a smile or a sneer, and have a significance in the
popular estimation hardly less prominent than it has in the professional mind.
Our range of observation need not be extensive to satisfy us of the truth of
this position. Reverence for age has become well nigh obsolete ; and the
younger branches of the community, instead of serving the elders, are most
emphatically served by them."

464

Bibliographical Notices.

[Oct.

Men.

Women.

Total.

137

196

143

778

245

148

In relation to hereditary predisposition, the two following cases are related :
" A young woman who a few years ago was under the care of this institution,
was immediately related to no fewer than ten persons who had destroyed them-
selves ; and she, too, died by her own hands."

"A woman, past fifty, of a well-balanced mind, began, about a year since,
to exhibit great irritability, and, a few months later, was seized with apoplexy
which resulted in insanity. She was immediately brought here, but died soon
after, in an attack of apoplexy. Two brothers, a sister, an uncle, and an
aunt, and several more distant relatives have terminated their lives in a simi-
lar way."

4. The record of changes at the Butler Hospital, is as follows : —

Patients on the 1st of January, 1856
Admitted . . . . ..

Whole number ....

Discharged, including deaths .
Remaining, Dec. 31st, 1856
Of those discharged, there were cured
Died . . ....

Whole number of patients from 1848 to 1856
Discharged, recovered ' .
Died .

One of the most interesting portions of this report is that which was sug-
gested by the recent presidential canvass. We extract the principal part of it : —

" It is worthy of remark that while the past year has witnessed a political
campaign which, as it regards the intensity of the feelings excited, and the
proportion of people actively engaged in it, is almost, if not quite, without
precedent, yet not a single admission could be fairly attributed to a political
origin. The fact is one of so much importance, as a matter of mental hygiene,
that it may be worth our while to consider it a little more closely. For days
and weeks and months, whole communities were living under a pressure of
excitement that made every other pursuit than that of politics a matter of sub-
ordinate interest. At home and abroad, by the fireside and in the market-place,
in private interviews and public gatherings, in mass meetings and evening pro-
cessions, in lectures and sermons, and speeches innumerable, by day and by
night, in season and out of season, the predominant feeling was manifested, as
if the dearest interests of the individual were staked upon the result. And
yet, after all this turmoil, no one, to my knowledge, was made insane by it.

" This kind of experience seems to confirm a conclusion, not entirely unsup-
ported by other considerations, that mere excitement alone is not necessarily
a very efficient agent in the production of mental disease. * * * Mental ex-
citement has been too readily regarded as amply sufficient, not only to disturb
the healthy balance of the faculties, but give rise to serious and overt disease.
In the cases which seem, at first sight, to warrant this conclusion, there will
be generally found, upon closer inspection, some additional element by which
the normal effect of simple excitement has been more or less modified. It may
be accomplished by an utter disregard of the plainest rules for the preserva-
tion of health. Food is taken irregularly, and the functions of the stomach
are disordered; the body, while improperly clad, is exposed to atmospherical
changes, and thus the sympathy between the skin and the lungs is deranged ;
the hours that should be given to repose are surrendered to the all-absorbing
topic, and for want of the blessed influences which ' tired nature's sweet re-
storer' diffuses over tho whole system, animal and organic, there occurs a
morbid irritability that deepens the impression made by every adverse incident.
Habits of daily exercise and recreation which have become essential to the
physical welfare, are entirely abandoned, and the brain is no longer visited by
the invigorating influences that radiate from the muscular system. Any one
of these incidents may impart to the mental excitement an unhealthy cha-

1857.]

American Insane Hospital Reports.

465

racter, and convert it into actual disease. It must be considered, also, that on
these occasions of prevalent excitement, all those exercises of the mind which
are promotive of peace, cheerfulness, and serenity ; that active interest in the
welfare of others which withdraws one from a too steady devotion to selfish
objects ; and especially those glimpses of a higher and brighter sphere, above
the agitations of flesh and sense, — all these may be replaced by a complete
absorption in the thought or emotion that holds possession of the individual."

Hereditary predisposition is also mentioned as one of the collateral elements
which may convert the excitement into disease ; and the fact is stated that
excitement is less liable to be injurious if the emotions which it excites are
pleasing than if they are depressing.

" Bearing in mind these views, we may readily see why the mental health
sustains so little harm generally from intense political excitement. It seldom
affects a person's habits of living. He takes his meals and exercise as regu-
larly as ever, and with as keen a relish ; his sleep is sound and his conscience
quiet; his sympathies are not entirely silenced; he acknowledges the claim of
his neighbour to a helping hand ; and his eye and ear are not utterly closed
to what is passing around him. The danger he apprehends, the good he seeks,
are somewhat remote ; and upon few comparatively of those who mingle in
political strife does the result have any immediate personal bearing. Their
business, their fortune, their social position, their domestic affections, remain
the same, whether the favourite candidate succeed or fail. The emotions
which spring from the joy of success, or the pain of failure, seldom come from
the depths of the soul, and cannot withstand the intrusion of other sentiments
more nearly connected with the ordinary experience. "

Yet it is not intended to convey the idea that political excitement is harm-
less. It is believed to be a part of that general mental activity of the age
which promotes disorders of the mind.

Dr. Ray now proceeds to show the difference between religious and political
excitement. We extract a part of his remarks: —

"The greater intensity of feeling produced by the former (religious excite-
ment) is to be attributed to the superior magnitude of the interests at stake.
They are no holiday matter which one may attend to or neglect without mate-
rially affecting his immediate welfare. They involve nothing less than his
future destiny, and are well calculated, if anything is, to produce serious
thought, if not overwhelming emotion. They also include an element of per-
sonal danger sufficient to excite apprehensions that seldom accompany the
gloomiest forebodings of national trouble. A sense of responsibility, quick-
ened by the consciousness of past deficiencies and neglected opportunities, also
helps to sharpen sensibilities already alive and glowing with excitement. The
attention being thus thoroughly aroused, the deepest concern and the strongest
emotion would seem to be indicative of the healthiest condition of mind. And
so indeed it would be regarded in a moral point of view; but we are made up
of body and mind, and the proper question is not what experiences are most
commendable abstractly considered, but what are most conducive to the wel-
fare and development of both. The activity of each must be in exact relation
to the power of the other, if we would avoid an imperfect and morbid result.
In certain exigencies, and especially when controlled by that sympathy which
unites people who are possessed by a common emotion, the will is apt to im-
pose upon the bodily powers an amount of effort beyond the healthy limit of
endurance. The intention is good and the object desirable ; but nevertheless
an organic law is infringed, and we pay the penalty in the shape of disorder
and disease. The successive steps that lead to this result are obvious enough
to the careful observer. In the pursuit of an object of paramount importance,
other objects are apt to be degraded below their proper level ; the healthy
balance of the mental functions, as well as the various duties of life, is de-
ranged; recreation and exercise are neglected; food is taken irregularly ; sleep
becomes less and less sound and refreshing ; and the whole nervous system is
strained to its utmost power of tension. Under such circumstances, the indi-
vidual is prepared for the invasion of any disease to which he mav be predis-
No. LXVIXL— Oct. 1857. 31

466

Bibliographical Notices.

[Oct.

posed ; and hence it happens that insanity is so common an accompaniment of
what is called religious excitement.

" Let me not be misunderstood. I have but poorly expressed my ideas if I
have conveyed the impression that, in this matter, religion, or the religious sen-
timent, is at fault. On the contrary I believe — and it is in some measure the
result of considerable observation of various psychological states — that, in this
age of fast living, nothing can be relied upon more surely for preserving the
healthy balance of the mental faculties than an earnest, practical conviction of
the great truths of Christianity. But in striving to obtain this conviction so
as to make it a guiding principle of life, as in the pursuit of any other com-
mendable object, the best designs may be imperfectly executed, and the best
intentions frustrated by reason of that all-pervading element of human con-
cerns, human infirmity."

So much for the abstract and the theoretical of this report. Let us turn for
a moment to the concrete and the practical. It having been determined to in-
troduce into the hospital the apparatus for heating by steam and ventilating
by mechanical power, " no time was lost in discussing plans for raising the
requisite funds" (115,000), but the whole amount " was subscribed upon the
spot" by the President and the Board of Trustees of the Institution.

5. In the report of the Hartford Retreat for the Insane, for the fiscal year
terminating with the 31st of March, 1856, Dr. Butler gives the following nu-
merical results : —

Patients in the Retreat March 31, 1855
Admitted in course of the year .
Whole number " " . .

Discharged, including deaths
Remaining March 31, 1856
Of those discharged, there were cured
Died . . . . ...

Deaths from exhaustion 5; diarrhoea 4; epilepsy 4 ; consumption 4; general
paralysis 2 ; apoplexy 1 ; old age 1 ; general debility 1 ; . disease of the brain"
1 ; suicide 1 ; erysipelas 1 ; purpura 1. Whole number admitted since 1824,
2,961. Discharged cured 1,463. Died 308.

The great distinguishing characteristic of the institutions for the insane of
the present day, is an enlightened moral treatment. That treatment is based
upon the law of kindness ; upon those better emotions and feelings of our
nature which, whether named benevolence or philanthropy, induce us to act
towards others with a single eye to their best welfare. But what is true kind-
ness towards the insane ? Does it consist in ministering to all their physical
necessities and comforts, and permitting them to do as they please ? By no
means. Is he a judicious, a truly kind parent, who feeds, and clothes, and
shelters, and educates, intellectually, his children, and yet suffers the baser
qualities of their moral nature to run riot, unchecked and unsubdued? Shall
the wayward child not be subjected to discipline, the froward curbed, the pas-
sionate taught to place a rein upon his anger ? Shall the boy whose unreason-
able demands have met with a refusal, whose desires have been ungratified,
or whose wilful and malevolent nature incites him to the acts, be permitted
to convert the house into a bedlam, and to maltreat, by both word and act,
every person who comes into his presence? Surely not. True kindness, the
ultimate and the best interests of the boy, demand that such conduct be not
permitted. But the insane, as was many years ago remarked by Esquirol, and
as must have been observed by every person long engaged in the management
of them, are very much like children. In their conduct, their feelings, their
motives to action, and their reasons or motives for repression of action, there
is a striking similarity. The number of the insane who have not generally
the power to control their actions, is but very limited. To teach them to exer-
cise that control is an essential part of their moral treatment. The sooner that
power is called forth, the sooner will they be restored to mental soundness.

Men.

Women.

Total.

108

193

157

155

195

350

153

197

1857.] American Insane Hospital Reports. 467

These remarks have been suggested by a portion of Dr. Butler's report, from
which we make an extract.

"That asylum for the insane is poorly cared for where the wants of the body
are alone abundantly provided for, while the cravings of the heart are left in
hunger and nakedness. Far better, in my view, to banish all other remedies
from the wards of such an asylum, than to leave them destitute of that per-
sonal, practical sympathy which, carrying to their hearts a conviction of its
entire sincerity and fellow-feeling, is daily active among them in cultivating
an equable healthy tone of feeling. Nor are cheerful influences alone de-
manded. Despondency is far from being the only unhealthy element developed.
Undue excitability, and the more coarse and violent elements of our nature are
here let loose, ready to run in wildest riot. Hence, in establishing the dis-
cipline of such a household, no reckless indulgence of passion, or of delusion,
capable of restraint, is to be allowed to violate its decorum, without such penal-
ties of reproof, banishment, or seclusion, as the good sense of every witness
will approve. The influence of a public sentiment which has been carefully
and thoroughly developed, and is kindly, yet decidedly applied, is of far greater
efficiency in promoting good order and discipline than most can imagine. This
position may be illustrated by a single example. A violent outbreak, both of
action and language, a short time since, compelled me to remove a young lady
to one of the lower departments of our system of classification, and thus to
deprive her of the privilege of refined society and pleasant associations ; I was
soon recalled at her urgent request, and found her in a paroxysm of tears.
She gave me the most earnest promises of future self-command and lady-like
deportment. I restored her at once to her former position, jocosely introducing
her to her old associates as an estimable young friend of mine from the country,
in whom I had great confidence. The lesson, benefiting others beside herself,
required no repetition. Its influence continued until entire restoration to
health speedily removed her from my care. Those whose frequent visits to our
house have afforded them a good opportunity of judging of the tone of feeling
of our family, can, perhaps, best appreciate the merits of such a system of
discipline."

Although not among the " frequent" visitors at the Retreat, yet we were
there, a few months ago, a sufficient time to enable us to form an opinion in
regard to the " tone of feeling" among the patients. Briefly, then, we may
assert that we have never visited an institution of the kind in which there was
more apparent cheerfulness and content; one in which the whole body of
patients appeared in a greater degree to have cast aside the individuality, re-
serve, and exclusiveness of strangers, and to have adopted the characteristics
of a united family. Dr. Butler has been untiring in his efforts for the attain-
ment of this end, and continues so, for its perpetuation. The patients are sur-
rounded by conditions and by agents ministering to their physical comforts ;
the walls of the corridors and the rooms are decorated with a multitude of the
better style of pictures ; social reunions and extempore dancing parties are of
frequent occurrence ; and the Doctor devotes much of his time to conversation
with the inmates of all classes, as he makes his daily visits to their several
departments.

6. At the Lunatic Asylum of King's County, N. Y. —

Admitted in the course of the year
Whole number ....
Discharged, including deaths
Remaining, July 31st, 1856 .
Of the discharged, there were cured
Died

Men.

Women.

Total.

, 75

110

185

. 65

145

. 140

190

330

. 60

136

. 651

1191

194

. 39

3 These are the numbers given in the report. To correspond with the preceding
figures, and to make the sum 194, they should be 80 and 114, instead of 65 and 119.

468

Bibliographical Notices.

[Oct.

"The general health of the patients has been remarkably good," says Dr.
Baiseley, "notwithstanding the crowded condition of our buildings. There
are in the Asylum, at the present time, fifty female patients more than can be
accommodated as they should be ; nor can they be classified in such a manner
as would be beneficial to them." He therefore recommends the building of
another wing. P. B.

Art. XX. — Indigenous Races of the Earth; or, New Chapters of Ethnological
Inquiry, including Monographs on Special Departments of Philology, Icono-
graphy, Cranioscopy, Palaeontology, Pathology, Archaeology, Comparative Geo-
' graphy, and Natural History; contributed by Alfred Maury, Bibliothecaire
de FInstitut de France, Secretaire General de la Societe de Geographie de
Paris, &c. ; Francis Pulszkt, of Lubocz and Cselfalva, Fellow of the Hun-
garian Academy, &c. ; and J. Aitken Meigs, M. D., Professor of the Insti-
tutes of Medicine in the Philadelphia College of Medicine, Librarian of the
Academy of Natural Sciences of Philada., &c. [with communications from
Prof. Jos. Leidy, M. D., and Prof. L. Agassiz, LL. D.] ; presenting fresh
investigations, documents, and materials ; by J. C. Nott, M. D., &c, and
Geo. R. Gliddon, &c. &c. Philadelphia : J. B. Lippincott & Co., 1857.

"Ethnology may have been regarded as a series of fanciful and, probably,
futile inquiries, leading to no very definite ends, and the ethnologist as a sort
of harmless visionary, led hither and thither by trifling indications, and excit-
ing more smiles than looks of satisfaction. In such a region, hypotheses have
been very prolific, and the pertinacity of their inventors has usually been in
the inverse ratio to their stability and the number of the facts on which they
have built them. Great learning has often been expended, even by men of
sterling merit, upon investigations into the origin, migrations, and settlements
of early nations, without any fixed principles or sound philosophy to guide or
to support the inquiries entered upon. ****** Such vague lucubrations
may be very fascinating, but are chiefly to be tolerated on the principle of the
old French maxim, ' Du choc des idees jaillit la lumiere/"

"It is the misfortune of new sciences that they afford none of those neces-
sary checks on individual folly and presumption without which learning is but
a despotic creed, or a clash of jarring opinions."

If such language has been, not long since, used by two very distinguished
ethnologists of the " diversitarian" school, J. Barnard Davis and Luke Burke,
we need not hesitate to accept its applicability, to some extent, to ethnology
now, when we read such works as the Types of Man and I.idigenous Races of
the Earth. These, both, contain much information, of which a sufficient propor-
tion is new ; they promise, in their titles, very great results ; not only the
mountains, but the deserts and plains, the mounds and the monuments " par-
turiunt ;" but, there is brought forth, at last, only hypothesis.

We have been, upon the whole, less disappointed with the present work than
with the Types of Man. It contains, like the latter, some articles marked by
great ability as well as research ; and, in one or two of them at least, displays
a more cautious spirit than the Types, so as to make it more worthy of scientific
attention.

The pages of a medical journal, however, afford but little space for the dis-
cussion of such subjects, whatever may be their interest. We shall be obliged,
therefore, to content ourselves with some very summary remarks, which, al-
though not hastily conceived, it will be impossible here fully to elucidate, or
to support with such references as they may seem to require.

After a brief communication from Lieut. Habersham, U. S. N., in regard-to
the "hairy Kubiles" and "red men of Formosa," a short letter is introduced,
from Prof. Agassiz. This contains a reassertion of his confidence in the theory
of " Natural Provinces," and its applicability to man, a brief allusion to the
complexional relations of monkeys and men, and a protest against the relia-

1857.]

Xott, and Grliddon, Indigenous Races of the Earth.

469

bility of philological evidence of race-derivation, upon grounds of zoological
analogy. We might remark, in passing, that the "identity of colour of the
Malays and Orangs," and of the " Hylobates with the Xegrillos and Telingans"
(a very interesting fact), would seem to he easily accounted for, by the similar
influence of climate and local conditions upon different species, without prov-
ing, or even suggesting, anything in regard to the origin of either.

The theory of " Natural Provinces" is the most consistent proposed upon
the side of the Polygenists. It advances the "coincidence of the geographical
distribution of the human races with that of animals," asserting that "the
adaptation of different races of men to different parts of the world must have
been intentional, as well as that of other beings ; that men were primitively
located in the various parts of the world they inhabit." It is asked, in the
words of Agassiz himself {Types of Man, p. 73), "how could it be supposed
that man alone would assume new peculiarities and features so different from
his primitive characteristics, whilst the animals and plants circumscribed
within the same limits would continue to preserve their natural relations to the
fauna and flora of other parts of the world ?" We may answer this, respect-
fully, with the simple inquiry — how is it that the distinguished author of this
question is himself a noble " exotic" from a distant land, and that he is in the
midst of a nation made up of the most varied elements, all of foreign racts, yet
which is increasing (as Wynne's late statistics show), irrespective of immigra-
tion, faster than any other on the globe ? Xor is such migration confined at
all to the Japetida*. The negroes, on the same continent, have, according to Dr.
Nott, in the Southern United States " assimilated readily to our climate," ex-
hibiting remarkable instances of longevity : the Jews pervade nearly every
longitude and latitude; and the Zingarri, or Gypsies, wander all over the world.
Degrees of mobility of species, therefore, must be acknowledged, as in the case,
also, of our domestic animals and cultivated plants ; and, this being the case,
hoic are tee to limit this short of the possibility of the province of Man reaching
from the central table lands of Asia to Iceland and to Terra del Fuego?

The theory of Specif c Centres, of Prof. Edward Forbes, may be believed
to be more in accordance with the facts of natural history. It maintains
the probable "origination of each species from a unique stock, or prototype,
consisting of a single being, or pair of beings, according as would be required
for propagation." This, with the law of variability, under known and unknown
causes, greater in some species than in others, and greatest in man and the
domestic animals, will account for all that we know of human distribution^
especially in view of its well established gradations.

To pass on. We have, next, in the book before us, a letter from Prof. Leidy.
It exemplifies the fact that the severest observer must, occasionally, indulge in
theory; while the success of its excursions is, perhaps, not facilitated by
desuetude. In the space of four pages, we are met by not less than three
hypotheses, in regard to the " traditions of the deluge," to the cotemporaneous-
ness of the " red man with the mastodon," and to the probable successive
creations of human races — to establish either of which would require the over-
turn of much supposed positive experience.

We may, in this place, allude to a very philosophical definition of species by
Dr. Leidy, quoted in another part of the volume. "A species is a mere con-
venient word with which naturalists empirically designate groups of organized
beings, possessing characters of comparative constancy, as far as historic ex-
perience has guided them in giving due weight to such constancy." This is
much safer than Morton's "primordial organic form." De Cand'olle and De
Blainville long since recognized the hypothetical nature of the ordinary defini-
tion, and its resulting inconvenience, which is especially evident in discussions
upon the diversities and origin of mankind.

Alfred Maury's essay on the Distribution and Classification of Tongues, &c,
is an admirably written (hardly so well translated) digest of comparative
philology, in which, after the assumption of the essential unity of the human
mind, so clear an account is given of the manner in which we may trace
almost every known tongue to an Asiatic relationship, that, but for an occa-
sional implication, and the concluding expressions, we should have supposed

470

Bibliographical Notices.

[Oct.

it to have been written by as " monogenistic" an author as Latham, or Johnes,
or Scheie De Vere.

Iconographic Researches on Human Races and their Art follows, by Francis
Pulszky. This is, also, ably written, and with research, although hardly so
complete in #ts method as the preceding. Races are classified, by Pulszky, as
"artistic" or " non-artistic ;" this characteristic being independent of their
general mental culture or capacity.

The Cranial Characteristics of the Races of Men, by J. Aitken Meigs, is the
next paper. This occupies one hundred and fifty pages, and is an elaborate
and complete monograph on cranioscopy in all its relations, as brought up to
the science of the present time. It is founded chiefly on the Mortonian collec-
tion of crania in the Philada. Academy of Natural Sciences, of which a new
catalogue has recently been issued by Dr. Meigs. The tone of this paper is
scientific, "carefully and designedly," to use the author's own language, "ab-
staining from the expression of any opinion upon the prematurely, and, per-
haps, in the present state of our knowledge, unwisely mooted questions of the
origin and primitive affiliations of man." The two most important, in our
view, of the conclusions to which Dr. Meigs has been led by his extensive
survey of craniology, are, that a regular system of gradation seems to underlie
and harmonize the various cranial forms of the human family, and, that these
forms display an inseparable connection with the physics of the globe.

Dr. Nott's views upon " acclimation, &c," are familiar, to some extent, to
the readers of this Journal. That medical climatology is, even with his inves-
tigations, in a yet imperfect state, and unfitted to afford a basis for ethnologi-
cal conclusions, will appear from the facts, that the so-called " autocthonous"
American Indians are now disappearing at a more rapid rate of mortality than
that of any other race (though all others are imported) upon the continent;1
and that, although Dr. Dowler is quoted as concluding that yellow fever is not
an African disease, the negro race is the only one which enjoys congenital
immunity from it. We have no room for criticism upon this paper, although
it invites it, especially by the boldness of the conclusions which it deduces
from premises which are rather less obvious to some of his readers at least than
to the author himself.

With regard to the contributions of G. R. Gliddon, which fill the last two
hundred and fifty pages of this volume, we find it somewhat difficult to con-
tinue in the same strain of remark. Their manner is the reverse of the scien-
tific, and their matter much less philosophical than that of his colleagues in
the work. Egypt is the favourite topic of his declamation, which wanders,
however, over many others, without restraint, and, apparently, almost without
object.

Upon the whole, the conclusion to which, so far, the ablest and most zealous
of naturalists, physiologists, philologists, and archaeologists, have, in large
majority, arrived, does not seem, notwithstanding the title of this work, to
have been altogether overturned by it. Entering upon its examination with
the most absolute impartiality, we must, still, be content to believe, with Lin-
naeus, Buffon, Cuvier, Blumenbach, Lawrence, Prichard, Lyell, Forbes, Miiller,
Owen, Carpenter, Flourens, Draper, Pickering, Latham, Lepsius, Bunsen, and
Humboldt, that man constitutes but a single species. Yet, the ethnology of
his varieties must ever be a most important subject — the crowning department
of physiology, and intimately related to psychology, history, and political sci-
ence. If its votaries will but cease confining their efforts to the establishment
of any particular dogma, whether of unity or diversity, its advances will be
more rapid, and its conquests more substantial, than any of those which the
editors of the present work have, as yet, in our view, accomplished.

The publishers of the Indigenous Races, by its typographical excellence, and
plenitude of illustration, have done all in their power to satisfy the expecta-
tions of the authors, and of their large list of subscribers. H. H.

1 Vide Array Med. Statistics, 1856.

1857.]

Annual Report of Marine Hospital at Quarantine.

471

Art. XXI. — Annual Report of the Physician-in- Chief of the Marine Hospital at
Quarantine. Presented to the Legislature of New York, February 4, 1857.
8vo. pp. 04: Albany, 1857.

The report of Dr. Harris, Physician of the Marine Hospital of New York,
is chiefly interesting from the history it presents of the yellow fever as it pre-
vailed during the summer of 1856, at different points along the shores of New
York Bay.

The first case of the disease was admitted into the Marine Hospital, Staten
Island, on the 18th of June, from on board of a vessel that had just arrived from
St. Jago de Cuba, where yellow fever was beginning to prevail when she left.
Between this date and the evening of the sixth of July, four other vessels, all
having the fever on board, arrived from Havana, where the disease was epi-
demic at the period of their departure. During the month of July, a number
of other vessels, with the disease on board, arrived from infected ports, and
were detained at the quarantine station. It was in persons from on board of
those vessels, or who were engaged in unloading their cargoes, or had visited
them, or been in their immediate vicinity, that all the first cases of yellow fever
in the vicinity of- New York occurred.

Previous to the 15th of July, several of the infected vessels lying at quarantine
had discharged cargo upon lighters under quarantine order. Up to that date
twenty-seven yellow fever vessels had arrived ; and of this number, ten or more
were lying at anchor nearly opposite the Marine Hospital, or at Gravesend
Bay. One had discharged a portion of her cargo, and, as subsequently ap-
peared, fourteen bales of filthy rags from on board had been stored in an open
shed on the U. S. Government dock at quarantine.

While lying at quarantine those vessels had destroyed, or cast into the bay,
large quantities of refuse matter, decaying fruits, old bedding, etc., and all
such matters as floated on the water were carried indirections and to localities
which became, subsequently, the lurking places of pestilence.

" The total number of seamen admitted to Marine Hospital with yellow fever,
immediately upon the arrival of the vessels from sickly ports, was seventy-two,
and these were received from thirty-three vessels. The number of cases re-
ceived, subsequently, from the same vessels was fourteen, from five of the ves-
sels. Besides these, there were fifteen seamen admitted with yellow fever from
nine other vessels arriving from infected ports, and upon which there was no
sickness at the time of arrival at quarantine. Thus., the total number of sea-
men admitted from vessels presumed to be infected was one hundred and one,
and these arrived on forty-four different vessels. Besides this number, six other
seamen having yellow fever were received from the city who had contracted the
malady from sources unknown. But as we shall have occasion to notice, in
another place, those persons had been peculiarly exposed in certain localities
about the city, where there is good reason to believe that the infection of yellow
fever existed."

Previously to July 22, five cases of yellow fever had occurred on the beach
I-4- mile south of the hospital, and near Townsend's dock; and six cases, of
which three died with black vomit, on the Long Island shore directly opposite
the quarantine grounds, between the 13th and 21st of July. From the latter
date the malady extended fearfully until it had visited nearly every dwelling
on the shore of the beautiful Bay Ridge ; thirty cases, and fifteen deaths having
occurred in that district previously to August 1.

A chronological summary is presented in the report of all the cases of yellow
fever that occurred, during the summer and autumn of 1856, in the port and
vicinity of New York. In this are recorded nve hundred and thirty-five cases,
three cases being added that occurred among patients convalescent from other
diseases in the Marine Hospital; it gives a total of five hundred and thirty-eight
well-authenticated cases, as ascertained by the most rigid investigation. Of
these, more than one-third died of black vomit. Of the twenty-nine cases
recorded as occurring in Brooklyn, seven were persons resident in the eastern

472

Bibliographical Notices.

[Oct.

district of that city, and twenty-two in the western district, or the City of Brook-
lyn proper. The origin of a large proportion of these cases, we are assured,
was traced directly to infected places and infected goods.

The first case of yellow fever occurred among the garrison on Governor's
Island, on July 29, and the malady continued to prevail quite steadily until the
10th of September. Though a very large number of cases occurred in that
military command, the victims were selected exclusively from the south battery,
which has a southerly and easterly exposure, facing, as it were, the quarantine
ground, and all those portions of the bay shores which, with propriety, might
be termed the great seat of infection. The officers of the command at Governor's
Island assured the author of the report that no material cause of infection was
conveyed to or existed upon the island.

" The first evidence of the presence of yellow fever in an endemic form in
the vicinity of the Marine Hospital was presented July 22, when two cases of
the malady occurred among the residents. All access to the grounds was imme-
diately cut off, as far as the physician in charge considered he had legal autho-
rity to prevent access to the establishment, and the health of the employees was
carefully guarded. The lodgings of the workmen were at once removed to the
highest elevation on the western section of the grounds. But the presence of
a large company of stevedores lodging in the government store every night,
and uneasy of the restraint imposed by the health officer's bonds, made it
necessary for the safety of the establishment, as well as the community beyond
the walls, that many of our men should serve on the night patrol. This was a
perilous service, in which several sickened.

"A very large amount of infected clothing from the sick, and bedding, etc.,
from infected vessels, were being constantly received and washed at the hospital
wash-house, which must be regarded as furnishing a favourable nidus for the
infection. Yet that building did not appear to be a source of general infection,
as its upper rooms were nightly filled with the stevedores who were unlading
vessels, and of whom none that lodged there suffered from the fever.

" From the fact that six persons who were employed at, or spent much time
in the gate-keeper's lodge, sickened with the fever at an early date, and, from
various other circumstances, we were led to conclude that the infected district
within the inclosure probably extended in a narrow zone by the water side
from the south to the north wall. "West of that section the ground rises to a
considerable elevation, and is terraced. None of the persons who remained
permanently beyond the first terrace suffered from the fever until the cool
autumnal nights appeared, when several very severe cases occurred in the
wards and dormitories on the hill.

" Many of those who performed night service seemed to be so saturated with
the poison of the malady that, when they yielded to its deadly power, they
advanced very rapidly to the stage of black vomit. Indeed, from the outset of
the endemic, the fever among the employees was observed to be of the most
malignant character — black vomit and hemorrhages occurring in many cases
as early as the thirty-sixth hour.

" The total number of officers and employees who suffered from the fever was
twenty-five, of whom five died. Besides these, there were eight other cases of
the malady among residents.

" Though the stevedores engaged in unlading infected cargoes began to suffer
from the fever as early as July 10, the pestilence had not gained any foothold
until July 17, when three cases occurred at the narrows, near Clifton Dock,
Staten Island. All the cases are readily accounted for without requiring proof
of any material fomites in or about the dwellings of those who became the
victims of the fever. But it is known that considerable refuse material from
vessels in quarantine was floated to the Staten Island beach by every flood tide.
Such was particularly true of the section north of the quarantine walls, and at
every ebbing tide refuse materials floated and lodged upon the beach near
Clifton, where the fever first became endemic on Staten Island. Twenty-nine
stevedores, resident on the island, contracted the fever, of whom all but one
were brought into the hospital. In addition to these, five stevedores sick with
the disease were admitted from the city.

1857.] Annual Report of Marine Hospital at Quarantine. 473

"Three fatal cases of yellow fever occurred previous to July 20, on the Long
Island beach, directly opposite to the Marine Hospital; and previous to July
27, fourteen cases had occurred, ten of which proved fatal. "

" The first two cases occurred on Mr. Hunt's place, a little below Greenwood
Cemetery, and about 300 paces off the beach. The two men were bathing in
the bay, Saturday evening, July 11, and examined a quantity of straw which
had been left on the beach by the receding tide, and requested their employer,
Mr. Bergen, to allow them to remove the straw to the farm yard. The follow-
ing Monday, one of these men was attacked with all the symptoms of yellow
fever, and the other man was attacked on the succeeding day. Both died with
black vomit. These men occupied a dormitory in an out-house, and, after they
had died, two other labourers were hired, lodged in the same room, and succes-
sively sickened and died with black vomit."

" Mr. M. Bergen was quite ill. He allowed nothing brought from the shore
to his dwelling, and was on board no vessel ; but his residence was very near
to, if not situated in the midst of a highly infected district."

On the beach, at the foot of 46th St., lived a Frenchman, a chiffonier, who
had been very busy gathering and drying refuse clothing, etc., which he picked
up along the shore. He sickened July 25, and died on the twenty-eighth. Dr.
Harris thinks it probable that in this manner the district in that vicinity became
infected.

July 26, Chandler White, Esq., was attacked with the fever, and died of black
vomit on the 8th of August. On the 28th of July, five cases of fever occurred
in four families near the Bay Ridge dock, north of Mr. White's, and of these,
three soon died with black vomit.

" August 1, the pestilence set its fatal seal on the Fort Hamilton district, a
mile south of Mr. White's residence, and near to the fort. On that day died
General Stanton, of the U. S. Army, and as his mansion was situated on an
elevation which looked out directly upon Gravesend Bay, and was surrounded
on the north and west by a dense grove, it was presumed that the deadly infec-
tion had been wafted to his delightful residence by southerly winds which swept
over the infected shipping at Gravesend. Previously to General Stanton's
death, a large number of vessels had discharged cargo at that anchorage for
infected shipping."

" On the day of General Stanton's death two soldiers in the Redout were
attacked with the fever, and up to August 8th, twelve cases had occurred in
the fort. The history of these cases was such as to convince the intelligent
and distinguished physician of the garrison at Fort Hamilton, that the infec-
tion had reached that stronghold by atmospheric agency only."

" Thirty-two cases of yellow fever occurred among the command at Fort
Hamilton, besides the case of its distinguished physician, Dr. J. H. Bailey,
whose unwearied labours for the relief of the pestilence-stricken population
beyond, as well as those within the fort, were terminated by a severe attack,
from which he finally recovered.

" It will be observed that we have noted three distinct and nearly equidis-
tant points at which yellow fever made its appearance on the Long Island
shore, between Gravesend Bay and Gowanus, a distance of nearly four miles.
Subsequently, viz., about the 10th of September, the fever made its appearance
in one house near Patridge's mill, near Coney Island. But those who became
its victims are believed to have handled materials that floated on shore from
the vessels. As regards the nature and mode of the infection received at the
first-named three points, there can be no doubt that at the two most southerly,
the cause and mode of access were atmospheric, while at the first, near Gowanus,
it may have been by material fo?nites."

" Fifty cases of yellow fever were admitted to the Marine Hospital from the
city of New York. Eight of these cases were traceable directly to Brooklyn,
and the origin of nearly all the others was traced directly to vessels which
were believed to be infected. The only exceptions, besides those which we
have previously mentioned, were : 1. Several seamen and one Italian organ-
grinder, from Water Street. 2. Six persons from the immediate vicinity of
pier No. 11, and Albany St., North River. 3. Two cases from the water side

474

Bibliographical Notices.

[Oct.

near the foot of 31st and 28th Streets, North River. All these were strongly
marked and unmistakable cases of yellow fever, several of them terminating
in black vomit, and there can be no doubt that in all of them the infection was
received at certain well known localities by the river side.

" Most of the cases of yellow fever which remained and were treated in the
city were traced to the infected shipping at quarantine. The cases admitted
into the hospital and traced to Brooklyn furnished no proof that any other
section of that city was infected than that which is situated between the
Atlantic Dock and the South Ferry. There were three cases, however, the his-
tory of which afforded evidence that, by some means, the infection of the fever
had reached some section near the Wallabout. But the etiology of these, like
that of the cases received from the vicinity of 31st Street, North Kiver, will,
perhaps, remain buried in obscurity. They occurred late in the season, and
may have originated from sources that did not expose others to danger/'

" September 4, four persons, the remaining members of a family in the 15th
ward, New York, were admitted to the Marine Hospital, two of them being
strongly marked cases of yellow fever. The mother" and son had died just pre-
viously ; the son's illness being yellow fever with black vomit. This family
had, for the purpose of sea-bathing, been residing for two or three weeks at
Craven Point, Bergen, N. J. The house they occupied was so situated that
at the highest tides it was nearly surrounded by water, and frequently there
was much refuse material, &c, left on the beach by the receding tide. The
owner of the dwelling suddenly sickened, and, after but a few days' illness,
died. His widow subsequently became ill with like symptoms, but recovered.
During the brief interim between these events, the family from New York re-
turned to their residence in the city, where, in the course of four days, the
first case of yellow fever occurred in the circle that had recently left their
pleasant residence by the seaside.

" July 23, a man from Bergen Shore, N. J., was admitted to the New York
City Hospital with yellow fever. He was a farm servant, and had not been
absent from the farm for a long period. He died July 24th."

Other cases occurred in Jersey City, and at other points upon the shore of
New Jersey, of which no accurate accounts have been obtained.

Dr. Harris refers next to what he considers the tidal agencies connected
with the production and spread of yellow fever during the period of which he
treats, and the meteorological phenomena of the season.

" The flood-tide," he remarks, " has great force in passing the Narrows, and
in the vicinity of Staten Island shore near Quarantine. Floating materials are
conveyed with great facility and certainty towards Craven Point and Jersey
City, as well as up both the North and the East Rivers. The receding or ebb-
ing tide returns such of those floating materials as do not find lodgment about
the shores just mentioned, back towards the Narrows, or down the Kill Van
Kull towards Newark Bay, the greater force being in the direction of Yellow
Hook, and Fort Hamilton, and Clifton. The entire beach of Yellow Hook is
the grand lodging-place for the refuse floating materials that are borne on the
receding tides of the upper bay. In that locality the pestilence first made its
appearance, prevailed longest, and was most malignant.

" There can be no doubt that the most active cause of the pestilence which
more than decimated the entire population of the water side in the last-men-
tioned locality was from the accumulation of infected materials floated from
the vessels in quarantine. We have already noticed the extension of the fever
to New Jersey shore by the same agency, and it is rational to presume that the
cases of fever which were admitted from the upper districts of New York and
Brooklyn received the infection from a similar cause.

" The agency of the tides, therefore, must be regarded as one of the most
important and active in diffusing yellow fever from the present quarantine
anchorage, especially as the distance to, and the location of the favourable
points for retaining floating materials is such, as to give the greatest facilities
for a ready deposit of such fomites."

The meteorological register given in the report was kept, as directed by
Government, at Fort Hamilton, by Dr. J. H. Bailey, U. S. Army.

1857.] Report on Origin of Yellow Fever in Norfolk in 1855.

475

" I will only refer in this place/' says Dr. H., " to one striking fact noted in
the register. Between the 21st and the 30th of July the wind was continually
from the southwest during the afternoon of each day, while the temperature
ranged unusually high (from 80.66, to 69.66, daily mean-average 76.3), and was
accompanied with a corresponding degree of humidity of the atmosphere.

" It will be recollected, that on the 29th of July, yellow fever was announced
as endemic at the fort and its vicinity ; and at the same time it was raging most
fearfully at quarantine. The same date also marks the commencement of the
endemic on Governor's Island."

From a careful examination of all the facts contained in the report of Dr.
Harris, of which we have thus given a very brief outline ; which facts appear
to us to have been collected with much care, and faithfully recorded, we think
that some important conclusions may be deduced.

First, the ganger of engendering malignant disease, by detaining a large
number of infected vessels upon the same anchorage ground, and in close
proximity to each other; especially during a season when the temperature and
hygrometric condition of the atmosphere are such as are adapted to promote
the development of disease.

Second, that the infectious air productive of yellow fever may be carried by
the wind to some distance from the locality at which it is generated, so as to
produce the disease in places where we have no reason to suppose that it would
otherwise have occurred.

Third, that the danger of the production of disease by an aerial poison con-
veyed by currents of air from infected ships or localities will be always in
direct proportion to the extent to which the healthy condition of the atmosphere
of places lying in the course of such currents is already impaired by local
causes, and the proximity of the places to the source of infection.

Fourth, that none of the facts contained in the report before us, prove posi-
tively that filthy clothing, bedding, etc., from on board of infected vessels, or
the damaged and refuse materials and garbage cast into the water from such
vessels, and conveyed by the tide and left by it upon the neighbouring shores,
act as material fomities of yellow fever, in the correct sense of the term ; or
that contact with them alone is capable of communicating the disease. There
can be no doubt, however, that the accumulation of any or all of the articles
and materials referred to, beneath a hot sun, and amid a humid and stag-
nant atmosphere will be liable to produce a condition of things well adapted to
favour the outbreak of yellow fever, increase the number of its subjects, and
augment its malignancy, when all the other elements for its production are
present, whatever these elements may be ; whether they consist of some un-
known endemic or epidemic influence, or the infected air from the holds of
vessels recently arrived from a yellow fever locality.

Fifth, there is not a single fact reported by Dr. H. that countenances, in the
slightest degree, the supposition of the spread of yellow fever by personal con-
tagion; on the contrary, the entire history of the disease as presented to us in
his report, would seem to be directly adverse to such supposition.

D. F. C.

Art. XXII. — Report on the Origin of the Yellow Fever in Norfolk during the
Summer of 1855, made to the City Councils by a Committee of Physicians.
8vo. pp. 44. Richmond, Va*, 1857.

The report of the committee appointed by the Councils of Norfolk, Va., to
investigate the cause and origin of the yellow fever which prevailed in that city
during the summer of 1855, presents a very full and apparently careful history
of the epidemic, from the occurrence of the first case until the disease had spread
over nearly every portion of the place.

The report commences with a sketch of the position and topography of Nor-

476

Bibliographical Notices.

[Oct.

folk, and a succinct account of the previous epidemics of yellow fever that have
occurred there.

The great object of the committee is to show that on no occasion, but more
especially in 1855, was the yellow fever generated in that city from local causes ;
that the state of the weather, in respect to its temperature and hygrometric
condition, was not such, either preceding or at the period of the outbreak of the
disease in the latter year, as is usually considered indispensable to the produc-
tion of yellow fever ; that, in the condition of the city, as to general un-
cleanliness, unpaved streets, the accumulation of putrefying materials in the
infected localities, recent excavations causing extensive disturbances of soil,
or the existence of any other local cause, was there anything by which the
origin of the disease there could be accounted for.

The committee refer to the steamer Ben Franklin, which arrived from St.
Thomas on the 6th of June, with yellow fever on board, as the source from
which the disease originated, and from whence it spread finally over the entire
town. Not, however, by contagion — not from the disease being communicated
from the sick to the well— but by the diffusion in the air, and the conveyance by
currents of wind of a material organic poison capable of rapid multiplication
in a congenial soil or atmosphere.

Taking all the leading facts as presented by the committee as correct— and
there is no reason whatever to dispute their entire accuracy — and admitting
that all the facts connected with the origin and spread of yellow fever in Nor-
folk during the summer of 1855 have been fairly reported by them, we cannot
but admit that the narrative given in the publication before us affords no little
support to the opinion of the committee that the epidemic of 1855 was the result
of the infectious atmosphere brought to Norfolk in the steamer Ben Franklin,
and that it was by the addition of this atmosphere to the malarious atmo-
sphere of the city that the latter became a cause of yellow fever in those exposed
to its influence. That, however, the atmosphere, of certain portions at least,
of Norfolk was in a condition ready to assume that peculiar morbific condition
generative of the disease must be admitted in order to sustain the position of
the committee, that the organic poisonous germs introduced into Norfolk by
the infected steamer required, as a suitable nidus for their reproduction, an
unwholesome atmosphere.

It is true that occasionally the committee in their report present statements
as facts, rather because such are essential to the establishment of the views
of the committee, than as clearly proved. A close investigation of the entire
chain of evidence exhibited in this report in support of the foreign origin of
the yellow fever in Norfolk during the summer of 1855 will, we think, discover
more than one link entirely wanting or essentially defective.

We lay before our readers the general conclusions of the committee in their
own language. In these we have a recapitulation of the leading facts in regard
to the origin of the epidemic, with their bearing, in the estimate of the com-
mittee.

" 1. The climate and situation of Norfolk cannot be very favourable to the
development of yellow fever, inasmuch as during a space of fifty years — viz.,
from 1805 to 1855 — the disease appeared among us as an epidemic but three
times ; viz., in 1821, 1826, and 1852.

" 2. The year 1855, previously to the outbreak of the fever, was not remark-
able either for heat or moisture. The temperature of the winter and spring,
except April, was below the average of thirty years. That of June was about
the average, but was exceeded in heat by fifteen Junes out of thirty, f The
heavy rains of April and May, followed by a long drought/ suggested in the
Portsmouth report as the cause of the fever, did not exist. On the contrary,
April and May were unusually dry, and June very wet.

" 3. The city, if not in as good sanitary condition as could have been desired,
was probably in as good order as most towns of the same size, and certainly as
clean as it had been for the last twenty-nine years, during which we had the
fever but once. There had been no recent filling up, and no excavation for
gas- or water-pipes, &c. During the progress of the epidemic, the cleanest,
dry est, and best-ventilated places enjoyed no greater exemption than the dirtiest

1857.] Report on Origin of Yellow Fever in Norfolk in 1855. 477

and most crowded, which would not have been the case if the disease were
owing to the decomposition of animal and vegetable matter.

"4. During the first six months of the year the health of the town was very
satisfactory. It was not merely as good as in preceding years, but, we think,
better. In June and July there was much less dysentery, the most common
disease of the season, than we ordinarily meet with.

" 5. In all previous epidemics the disease began in Norfolk, and only ex-
tended, after the lapse of many weeks, to Portsmouth and Go§port, where it
prevailed to a much more limited extent than in Norfolk. This circumstance
was probably owing to the fact that all vessels from the West Indies come to
Norfolk, and none to Portsmouth, which has had little or no commerce.

l< 6. In two of the three epidemics which have occurred in the last half cen-
tury— viz., those of 1821 and 1852 — the disease has been traced with great
probability, if not certainty, to vessels arriving from West India ports with
fever on board. That of 1826, of which, unfortunately, we have no recorded
history, was attributed by popular opinion to a similar source.

"7. The fever of 1855 began in Gosport, the first cases being on the 30th of
June, in a house adjoining Page and Allen's ship-yard, in a locality where there
are no unusual elements of disease. The surface of the yard, it is true, was
covered with chips, as is the case with all ship-yards ; but, after a careful and
minute personal examination of the premises, we have been unable to discover
any obvious or probable cause of disease. The dock which has been pointed
out as the 'fons et origo mali,' the very focus from which the poison emanated,
though partially filled with mud and logs of timber, is covered by salt-water
at high tide, and, in our opinion, is altogether inadequate to the production of
disease of any kind. The marshes around Gosport, and which are not in the
immediate vicinity of Page and Allen's yard, are in much the same condition
as they have always been — very unsightly when the tide is out, and giving rise,
when partially obstructed, to intermittent and remittent fevers ; but as they
have never caused yellow fever before, in the last fifty or one hundred years,
we are at a loss to understand how they could suddenly have acquired this new
potency in 1855.

"8. On the 19th of June, eleven days before the first cases of fever were
seen in Gosport, it is worthy of note, that this was about the time that has
frequently been observed to intervene between the arrival of an infected vessel
and the first cases of fever ashore — the steamer Ben Franklin from St. Thomas,
came to Gosport, and was laid alongside the wharf at Page and Allen's
yard, at the distance of not more than one hundred yards from the house in
which the first cases occurred. This ship had lain a long time in the harbour
of St. Thomas, where the fever was very prevalent. She had probably lost
several of her crew while there, and had certainly lost two men by fever on
the voyage to this port. When, after remaining thirteen days in quarantine,
she came up to Gosport, there was a severe and fatal case of fever concealed
on board of her. While she lay at the yard, three other cases occurred among
those employed on board of her; viz., one on the 30th of June, another on the
same day, or 3d of July, and a third on the 5th of July. Cases continued to
break out on board of her after she was sent back to quarantine, not only
among the crew, but in two negroes who spent a night on board of her — thus
showing that the vessel was infected.

" 9. The fever began in Norfolk in Barry's Row, on the 16th of July, just 17
days after its commencement in Gosport, 28 days after the Ben Franklin ar-
rived at Page and Allen's yard, and 40 days after her arrival at quarantine.
Barry's Row is situated northeast by north from Page and Allen's yard, and
is 1.07 mile distant from it, with only water intervening. From the time
of the arrival of the Ben Franklin at Gosport to the outbreak of the fever in
Barry's Row, the wind prevailed almost constantly from the southwest. We
have no evidence that the disease was conveyed to Norfolk in the baggage of
fugitives from Gosport, as was currently reported at the time ; but we incline
to the opinion that the material cause of the disease was transported by the
wind directly from Gosport or the Ben Franklin, and found a suitable nidus
for its further development in the low, dirty habitations of Barry's Row. Nei-

478

Bibliographical Notices.

[Oct.

ther was the distance — 1.07 mile — too great, nor the time — 28 days — too short
for this occurrence. In this opinion we have been strengthened by the fact,
that the next year, 1856, the yellow fever was thus communicated from vessels
at quarantine to the Long Island shore, in the neighbourhood of Fort Hamilton,
N. Y., where, when once planted, it continued to spread until frost.

" 10. The disease did not break out simultaneously in all parts of the city,
as it would have done, if produced by a combination of terrene and meteoro-
logical causes,, nor was it scattered about as if by accident, as is the case with
diseases propagated by contagion; but, starting from a central point, it ad-
vanced steadily and regularly in all directions, until arrested by frost — there
being an interval of two months between its commencement in Barry's Row,
and its appearance on the Princess Anne road, a distance of 1£ mile, and more
than three months from the first case in Gosport to the occurrence of the dis-
ease in the extreme limits of Norfolk.

" 11. The yellow fever north of the Gulf of Mexico is well known to be a
disease of seaport towns only — never appearing in inland towns, unless pre-
viously existing in neighbouring seaports. When it occurs in seaports, it very
generally begins on the wharves in the neighbourhood of shipping. We know
of no causes, either local or meteorological, which are peculiar to seaport towns
and the commercial parts of those seaports, and which are not equally found
in inland towns, except the presence of ships from foreign ports. Accordingly,
the common sense of the people, regardless of professional dogmas and theo-
ries, has always ascribed the origin of the disease to importation in ships.

" 12. The fever in 1855 did not appear, in any case that came under our
observation, to be communicated by contagion. Indeed, the greater number
of instances in which persons from Norfolk died with yellow fever in other
places, without communicating the disease, proves, as far as negative testimony
can prove anything, that the disease is, decidedly, not contagious.

" Finally. After a careful consideration of the foregoing facts, we are una-
nimously of the opinion that the yellow fever of 1855 was introduced by the
steamer Ben Franklin from St. Thomas, and that there is no reason to suppose
that we should have been visited by the epidemic but for the arrival in our har-
bour of this or some other vessel with the fever on board.

"In the present state of science, it is not possible to determine what is the
material cause of yellow fever, inasmuch as it is not tangible, and cannot be
subjected to examination and analysis. It is only by a careful process of in-
duction from all the known facts in relation to the disease, that we can hope
to arrive at a correct theory of its origin and propagation. The hypothesis,
which best explains most of the known phenomena of the disease, is that its
material cause is some organic matter endued with the property of rapid re-
production, either in a soil or atmosphere congenial to it, but not capable of
being reproduced in the human body. That this matter, whether of animalcu-
lar or vegetable character, is a production of tropical regions, and is only
spread in temperate climates, when introduced into them by ships.

" As a necessary consequence of our opinions, we would advise councils
that, while they should pay the strictest attention to sanitary regulations, such
as cleaning, draining, &c, with a view to diminish, if possible, the spread and
malignancy of the disease, in case it should unfortunately be introduced, yet
our chief reliance for escape from yellow fever for the future must be in a
rigid quarantine, at a safe distance, of all vessels arriving from suspected
ports."

The report, with the foregoing conclusions as those deducible from the facts
detailed in it, is signed by five members of the committee. The member
whose name is not appended to it, dissents from the proposition contained in
the 9th of the general conclusions asserted by his colleagues, " that the yellow
fever poison was wafted by the wind from Gosport, and found a suitable nidus
for its further development in the low and dirty habitations of Barry's Row,
Norfolk." He " thinks it more likely that either the ferry steamer, plying
twice daily between the original seat of disease at Gosport, and the vicinity of
Barry's Row, or the workmen on board of her, acted as the communicating
agent of disease."

1857.]

Williams, Principles of Medicine.

479

In reference to the question of contagion, his observation, he remarks, " fa-
voured an affirmative opinion." He thinks that the cause of yellow fever is
some minute material germ, capable of reproducing itself when given off from
the human body suffering under the disease.

If, he remarks, he should hazard any opinion in addition to that given in the
report, it would be "to remove all persons sick of yellow fever as far as possi-
ble from a crowded city population, and especially from that of the labouring
Irish, who now abound in Norfolk."

D. F. C.

Art. XXIII. — Principles of Medicine. An Elementary View of the Causes, Na-
ture, Treatment, Diagnosis and Prognosis of Disease, with Brief Remarks on
Hygienics or the Preservation of Health. By Charles J. B. Williams, M. D.,
F. R. S. A new American from the third and revised London edition.
Philadelphia: Blanchard & Lea, 1857. 8vo. pp. 486.

The views of the author in preparing this work are set forth in the first
paragraph of the preface to the present edition, as follows: "In this work
the attempt is made to place the practice of medicine on a footing somewhat
corresponding with that of physiology, chemistry, and other sciences which
equally depend on the accurate observation and rational arrangement of facts.
If our knowledge of the healthy body, and of its parts and functions be exact,
it ought to be our best guide in the study of the same parts and functions in a
state of disease. Yet the belief has long prevailed, and even still has its
avowed advocates, of regarding the phenomena of disease as a new and sepa-
rate order of things, the character and laws of which are to be investigated
by themselves, and without reference to the standard of health from which
they deviate ; as if diseases were independent entities, and as if the body
under their influence ceased to possess the same structures and functions
which it has in health. Happily, however, such irrational dogmas do not now
find much favour with the members of our profession, who, in proportion as
they become more enlightened by sound physiology, recognize in it when con-
tinued with careful clinical and pathological observation, the best guide to the
understanding and treatment of disease."

We quote these views as consonant with sound medical philosophy and the
true basis of the principles of medicine. The tendency of the mind to oscil-
late between extremes has been exemplified by the currents of medical opinion
during the last twenty-five years. At the commencement of this period the
practice of medicine was wholly subordinate to medical doctrines. The prac-
tical notions of physicians were determined by their speculative opinions,
leading to directly opposite methods of treating diseases according as they
adopted the doctrine of Brown on the one hand, or that of Broussais on the
other hand. Theoretical medicine was, in fact, a theory in the ordinary
acceptation of this term, and practical medicine was, in other words, a system
of practice constructed in strict conformity with theoretical principles.

Clinical observation and numerical analysis marked a new epoch. Medical
opinions and practice were to be emancipated from the tyranny of theoretical
dogmas. These methods of investigation, heretofore too much neglected,
already productive of great results, and promising for the future incalculable
benefits to medical science, have yet, in some minds, been invested with an
importance too exclusive. The extreme in this direction is exemplified in the
notion that the principles of pathology are deducible only from observations
at the bedside, and that empirical knowledge is the sole basis of therapeutics.

Sound philosophy and common sense dictate a middle course between these
extremes. To develop the laws of disease and the effects of remedies by
accurate observation and statistical researches, are objects which cannot be
overrated except by regarding them as the only means of arriving at truth.
On the other hand, the direct pathological bearing of progressive increase of
our knowledge of anatomy and physiology, must not lead the medical philoso-
pher to disparage the labour of the clinical observer and analyst. True it is

480

Bibliographical Notices.

[Oct.

that the phenomena of disease are but the phenomena of life presented under
an abnormal point of view. The distinction between physiology and patho-
logy is arbitrary; .in reality they constitute one science, and just in proportion
as we become more correctly and intimately acquainted with the structure
and operations of the living organism in health, are we qualified to understand
more fully the alterations which this organism presents in disease.

These remarks may seem trite to some of our readers. They have been
suggested by the quotation above given, and do not seem to us out of place in
view of the fact that the two extremes of medical opinions just indicated, have
each its representatives in the ranks of the profession.

Dr. "Williams' work on the principles of medicine has been for several years
well known to medical readers on this side of the Atlantic. The call for a
republication of the third edition is evidence of the favour with which it has
been regarded. Much the larger portion of the volume (327 pages) is occupied
with the consideration of the primary and proximate elements of disease and
structural affections. The remainder (159 pages) is devoted to etiology, semei-
ology, diagnosis, prognosis, and hygienics. The author's plan is to exhibit a
concise view of the deviations from the normal composition, structural arrange-
ment and functions of the organism so far as these are at present known, and
to trace the rational applications of this knowledge to the practice of medicine.

To any who appreciate the activity and progress characterizing the study of
the organism in health and disease, it must be sufficiently apparent, that the
rational principles of medicine at the present moment cannot be expected to
be altogether permanent. In fact, the principles of medicine now, or at any
given period, must be, to a greater or less extent, provisional. Some practical
truths will remain unchanged, but the greater number of principles which
appear to be, and indeed are most consistent with existing knowledge, will, in
all probability, undergo important modifications, if not displaced by new views
which, in their turn, may be compelled to give way to others more consonant
with the progressive developments of science. If the instability of pathology
be made an occasion for reproach, who does not see that medicine would be
far less entitled to our respect had a misguided conservatism held tenaciously
to all the doctrines in vogue but a few years ago ! Who does not see in this
very instability encouragement to look for future developments which may
vastly enhance the character of medicine as a science and its usefulness as an
art!

The plan of Dr. Williams' work we regard as well devised, and in the main,
well executed. Although the first edition was published but a few years ago,
the advances made in the several departments of biology render necessary
important modifications of some of the views enunciated in that edition, as
well as newly added views. It is intrinsically difficult to adapt successive
editions of a text-book in any science to the changes incident to the progress
of the science if the latter be actively progressing. This difficulty is apparent
in the present instance. Moreover, in bringing a new edition up to the exist-
ing state of the science, an author's partiality for his work inclines him to
make the requisite alterations appear as small as possible. His egotism is
wounded by striking inconsistencies on comparing late and previous editions.
The justness of this remark is evidenced in this instance. Considerable in-
genuity is shown in attempts to trace an identity in the observations contained
in the first edition and in recent scientific developments. Were we to write a
review of the work (which at this time is not called for), we should find scope
for criticism in the overweening desire which the author manifests to maintain
consistency of opinion ; in the representations of opinions or hypothesis in
the light of well established facts ; in the looseness of certain statements, and
a disposition to attempt to explain everything instead of fairly confessing
ignorance when our present knowledge is defective. In view of these blem-
ishes, a newly written work on the principles of medicine might be made more
acceptable, and seem to us to be in a measure needed. Until we have a
work embodying more freshly the facts and deductions pertaining to medical
pathology at the present stage of its progress, the " Principles of Medicine'' by
Dr. Williams will maintain the position of an useful elementary treatise.

A. F.

1857.] Blair, Yellow Fever Epidemic of British Guiana. 481

Art. XXIY. — Report of the Recent Yellow Fever Epidemic of British Guiana.
By Daniel Blair, M. D., Surgeon-General of British Guiana. 8vo. pp. 91;
London, 1856.

Tee Report of Dr. Blair is one of considerable interest. Besides presenting
a summary of the history of yellow fever as it prevailed in British Guiana, in
the years 1852 and 1853, it indicates several important points in reference to
the symptomatology and morbid anatomy of the disease that have not been
prominently noticed by previous observers.

From the beginning of 1845, the health of the seamen in the harbour of
Georgetown, Demerara, and of the inhabitants, generally, of the entire colony
of British Guiana, was, we are informed, good. During four months of 1850,
from June to September inclusive, mumps became epidemic and. epizootic,
being very fatal to cattle. From the latter part of July to the latter part of
August, of the ensuing year, a malignant influenza swept over the country and
destroyed many of the feeble and dissipated among the Coolie and Portuguese
immigrant population, but was scarcely felt by the seamen. In fact, until the
end of 1851, the harbour of Georgetown might have ranked, we are assured,
among the healthiest in the world ; and no disease existed in the colony of
which the newly arrived European or North American need have had the
slightest apprehension.

The years 1851 and 1852 were remarkable for the favourableness of the sea-
sons, indicated by the extraordinary average yield of the sugar crops. From
1849, a great change took place in the distribution of rain over the colony.
That year was the acme of the rainy years. Previously, and up to 1851, the
rain and dry weather appear, in the meteorological charts, gathered up in large
masses, but since then there has been a less quantity, and greater dispersion.
During 1851, the rain was so equally distributed over all the months, that no
great washing or drying of the country took place.

" The meteorological characteristic of the weather preceding and accompa-
nying the advent of the yellow fever, therefore," remarks Dr. B., " was the
absence of any decided dry, or any decided rainy season. It was favourable to
vegetation and agreeable to the feelings; and the minimum temperature of six
years occurred in the month of January, 1852 (13th), when the thermometer
fell as low as 67.7°. The coincidence of the invasion of yellow fever with the
most cool and agreeable time of the year, corresponded in this respect with
the epidemic that preceded ours along the windward coast of South America ;
that of Cayenne having commenced about the end of November, 1850, and
that of Surinam about the end of January, 1851.

" Although our former epidemic had every appearance of local origin only,
that from which the colony now suffers would seem to be the result of some
general exciting cause acting consecutively along the southeastern seaboard of
America, which, beginning at the Brazils, passed on to French, then Dutch,
then British Guiana — thence to the "West India Islands, New Orleans, and,
finally, Bermuda. Had the winter not interfered, probably Philadelphia and
New York would have been reached. Although, if its diffusion was due to the
agency of the trade-winds solely, whose course it followed, the latitude of Ber-
muda should have been its terminus. The hypothesis of a great epidemic
wave, rising in the east, and flowing on westerly, only apparently suffers from
a minute inquiry into its course — for, although Demerara was invaded at the
end of 1851, while Berbice, which is easterly, or to windward, did not suffer
seriously till the end of July, 1852, still, in New Amsterdam, the port and
capital of the latter country, two fatal cases occurred as early as February,
1852, and one in May following ; and it is to be considered, that this town
(unlike Georgetown) is situated several miles above the mouth of its river, and
may have been caught, so to speak, in the eddy of that great epidemic wave,
which so peculiarly affects the sea margins.

" Although the present epidemic has been apparently more intense and dif-
No. LXVIII. — Oct. 1857. 32

482

Bibliographical Notices.

[Oct.

fusive than its predecessor, and its origin seems referable to a foreign source,
still it affects special localities as before ; and the tenements which suffered
most on a former occasion, have been again those of its severest visitation s."

" The march of the epidemic, its dates and lines of diffusion, would indicate
the influence of atmospheric currents on its progress. Outside the boundaries
of epidemic influence there was safety. The danger seemed in some measure
proportioned to the nearness of approach to the centre of infection ; and seve-
ral striking instances have occurred, of parties descending, on a visit, from the
uplands in the interior, and the unaffected regions of the coast, falling victims
to the infection of the town. Within its circumscribed range, the epidemic
manifested local predilections, and though some places seemed permanently
affected, the lines of infection occasionally shifted, as in the former epidemic,
and infected and unaffected localities were temporarily in juxtaposition.

" Lulls and exacerbations in the general violence and intensity of the epide-
mic were frequently observed in its course. The first of these lulls occurred
in the last half of the month of March, and the first exacerbation in June. By
the end of August, another lull, but of short duration. In February and
March, 1853, the epidemic power was intense. It moderated again till June,
when it was renewed with great virulence. These lulls in the epidemic were
as illusive as the lull of symptoms in the fatal progress of the disease ; and it
was often my painful duty to discourage the hopes that were so eagerly enter-
tained by the authorities and the public, of the entire and speedy disappear-
ance of the epidemic, and to resist, with apparent pertinacity, the repeated
proposals for the return of the white troops to the military service of the co-
lony.

" Although the epidemic sprung up at a delightful season of the year, when
the general health was excellent, and, perhaps, irrespective of weather, yet, in
its course it seemed materially influenced by meteorological conditions ; and
sometimes even diurnal variations were observable in the condition of the whole
of the patients in the hospital, which could only be referable to atmospheric
causes. A cool, dry, brisk air seemed to have a mitigating effect, while a hot,
sultry, close, moist air increased the number of admissions, and aggravated the
type of the disease, particularly on its immediately following the other meteor-
ological state."

Dr. Blair notices the occasional blending of yellow with intermitting fever,
and its modification in some cases by influenza. In June, 1853, smallpox be-
came very prevalent, and was suspected in some cases to be of spontaneous
origin. Mixed cases of smallpox and yellow fever occasionally occurred, the
former disease predominating; if, after the stage of desquamation, smallpox
patients were attacked with yellow fever, the latter then had its own course,
unmolested. The coexistence of pneumonia and pleuritis with yellow fever,
sometimes the one, and sometimes the other being primary, was of frequent
occurrence, particularly among the Portuguese immigrants.

It is stated by Dr. B. that, in the course of the epidemic, several long-stand-
ing cases of chronic disease, to the consternation and surprise of the by-
standers, terminated suddenly and fatally by black vomit without any precur-
sory fever.

Not only was the epidemic, as a whole, subject to modifications and fluctua-
tions, but the early individual symptoms of the disease also.

" Sometimes/7 remarks Dr. B., u the full complement of standard symptoms
were present, sometimes they were imperfect or deficient, and sometimes dis-
placed. At one time the diagnostic symptom was the supra-orbital headache.
This, in the epidemics of Cayenne and Surinam, seems to have been the con-
stant characteristic, accompanied, generally, by lumbar pain. At other times,
the tongue symptoms alone were diagnostic. Sometimes their equivalent was
observed in the fauces and uvula. In the Surinam and Cayenne epidemics our
tongue symptoms do not seem to have been at all recognized. These variations
and shiftings of the symptoms were not irregular or promiscuous, but periodi-
cal; and they continued steadily for several weeks together." "Intense sur-
face heat, early albumen in urine, and early black vomit, were the character of
the later symptoms ; and smoky, pale urine, with perfect blood-corpuscles, took

1857.] Blair, Yellow Fever Epidemic of British Guiana.

483

the place of the straw-coloured or bilious urine, with its sediment of tube-casts
and epithelial matter. Notwithstanding this variation of symptoms, they were
never so defective as to prevent the formation of a correct estimate of the nature
of the disease with which the practitioner had to deal. The variation of symp-
toms had sometimes a relation to the mode of accession of the disease. In the
diarrhoeal or choleroid cases, the tongue and head symptoms werev seldom so
early or developed."

It will be impossible for us to follow Dr. B. in his most interesting account
of the several symptoms of the disease.

The supra-orbital pain, and punctated tongue, Dr. B. considers as most
valuable premonitory symptoms, the first, especially, giving notice of an im-
pending attack several days before it occurs. These symptoms, also, indicated
the epidemic taint in some cases of intermittents, which resisted the ordinary
treatment of such cases.

The frontal pain seems normally to belong only to the formative and febrile
stages of yellow fever, and subsides spontaneously in the middle and late
stages. It is sometimes described as in the orbits, more rarely in the upper
part of the forehead ; occasionally as extending to the occiput. It is usually
attended by an increase of temperature over the forehead.

Dr. B. describes a specific capillary irritation that shows itself in the flush
of the face, and which he pronounces as characteristic of yellow fever as the
hectic of phthisis, or the fuliginous complexion of typhus.

"This suffusion," he remarks, "generally occupies a zone over the eyes, and
about an inch above and below them. The eyes are injected, like those of a
person just awake, but generally without any lachrymation or photophobia,
although the injection may be as intense as in ophthalmia. Sometimes the
irritation extends to the palpebrae, to one or both, and sometimes only one eye
is affected, but that so violently, as if the patient had been stung, or received a
blow on the eyes." " The nares also may be found injected, with a coarse vas-
cularity ; the lips may be crimson or vermilion coloured ; the tongue scarlet at
tip and edges. If the fauces be examined, the roof of the hard palate will be
sometimes found covered with a coarse network of capillaries, which extends
to the uvula. If the practitioner is already satisfied as to the nature of the
case, this examination of the fauces should be omitted, on account of the vomi-
turitis generally induced by pressing down the tongue preliminary to the exa-
mination."

Dr. B. also remarks, that, upon a careful examination of the chest, a sub-
cutaneous rash may sometimes be observed, which occasionally extends to the
arms and abdomen. The face, chest, arms, and legs have likewise, in some
cases, a slight purplish appearance after the second or third day, and some-
times the colour of a boiled lobster.

"This appearance varies much in degree, but may be detected by pressing
the hand flat on the chest, when the fingers will for a short time be delineated
in white with purple outline. This symptom occurs chiefly in the ' smoulder-
ing' form of the disease, and is often so deep as to conceal the jaundiced ap-
pearance of the skin."

The appearance of this languid capillary circulation, as it is called in the hos-
pital case-books, is looked upon, says Dr. B., with favour. It would seem to
indicate, he adds, that the congestions were directing themselves towards the
periphery of the body, thus relieving the vital internal organs from a part of
their load. In these cases the skin is generally cool and moist, and sudamina
occasionally appear.

The appearance of the tongue in yellow fever, and the variations presented
by the organ in different cases, and in the different stages of the same case, are
minutely detailed by Dr. B. ; in these details, however, interesting as they are,
we cannot follow him. The same remarks will apply also to his description of
the condition of the urine, and the changes it undergoes in the course of the
disease. He describes it as always acid in the first stage, and continuing so
generally until convalescence, when it becomes alkaline, or until it becomes
heavily charged with bile. He confirms the accuracy of Dr. Collings' observa-
tions in regard to albuminosity of urine as a characteristic of yellow fever. The

484

Bibliographical Notices.

[Oct.

albumen generally appears on the second or third day; it has been found as
early as the first day of illness, while, in a few cases, it did not appear till the
day of death, and after black vomit had set in. It was seldom seen in aborted
cases. In a few instances it appeared in these during convalescence. In three
cases the albuminosity was intermittent for one or two days.

" Albumen appeared in every fatal case of normal duration. It sometimes
ceased in convalescence suddenly, always before the yellow suffusion of skin
and eye, or bile in the urine, disappeared, except in a single case, where
Bright' s disease seemed to be a sequel of yellow fever ; the patient, after re-
maining in hospital upwards of two months, left with his urine still albu-
minous. Between the eleventh and twentieth day of gravior cases, it generally
disappeared, and its disappearance formed the criterion for the discharge of the
patient from the hospital. The colour of the precipitated albumen was never
white, as it is in our cases of Bright' s disease."

" The turbidity of the urine was not necessarily connected with its albumin-
osity. The urine may be deeply tinted with bile, and highly albuminous, and
yet clear. The turbidity of the urine was caused by the presence of mucous
epithelial matter, coagulated albumen, and casts of the urinary tubuli. It is
probable that the free acid of the urine has a coagulating power, and some-
times communicates turbidity. The presence of mucus will have a similar
effect, but the turbidity then is not general, but occupies a lower stratum of
the fluid, and is light and floating there, while the supernatant liquid is clear.
There is nothing distinctive or of importance in this mucous condition when
the urinary secretion is copious. Perfect epithelial scales are rarely found in
the sediment, but broken up epithelial matter is abundant." " Although albu-
minosity is almost always the antecedent to the presence of tube-casts, a case
occurred in which these were found in non-albuminous urine."

The albuminosity of the urine furnishes, Dr. B. observes, one of the most
obvious manifestations of yellow fever entering its second stage, and its exten-
sion to the great solid viscera.

"Cases have died even when the urine was full and free; but life is pro-
longed thereby ; and no guarantee of safety in one epidemic was so sure as an
unobstructed action of the kidneys; and no sign, not even black vomit, so
dooming as a suppression of urine. Hope then was gone. No matter how
desperate the condition otherwise, if there was copious transparent urine,
though ever so coagulable, and black as ink from bile, the struggle was hope-
fully maintained. For it was felt that the system was still competent to the
elimination or decomposition of the yellow fever poison. But suppression after
the abundant appearance, or curdy aspect of albumen and tube-casts, rendered
despair reasonable. The scanty oily-looking urine was generally present in
cases that might be abandoned. The tube-casts had disappeared — for the ca-
pability of washing out these plugs of the urinary tubules no longer existed : they
are irrecoverably choked ; and the bulk of the scanty secretion seemed to be
derived, not from the kidney, but the bladder itself."

A very instructive chapter is given by Dr. B. on the ejections from the sto-
mach in yellow fever. In the early period of the attack the matters vomited
are alkaline. When the second stage of the disease sets in, on the second,
third, fourth, or as late as the fifth day of the disease, they become acid, and
continue so to the close of the disease ; the acidity being most decided during
the production of black vomit. The acid discharge may, at first, consist of a
quantity of clear, pale, almost limpid or slightly opalescent fluid. With this
ejection the disease may terminate, or go on to a protracted period, without
change in the matter vomited, usually, however, it is the precursor of the black
vomit, the acid ejections becoming mixed to a greater or less extent, with snuff-
like specks, before it merges into well-defined black vomit. " Normal black
vomit," is described by Dr. B. " as having a laminar or granular sediment, of
a deeper or paler shade of brown, sometimes verging on jet black, with a
clearly defined supernatant serum of low specific gravity, and without muco-
sity, partaking of the colour of the sediment, but sometimes nearly limpid when
the sediment is black, as if all the colouring matter had subsided. Many de-

1857.] Blair, Yellow Fever Epidemic of British Guiana.

485

viations from this standard occur from the presence of ingesta, hemorrhage,
and excessive secretion of mucus."

" The sediment of black vomit seemed to consist of coagulated albumen and
the debris of blood-cells. In no case in which the black vomit was normal to
the eye, was a single perfect corpuscle observed. When pressed through a
paper filter the colour is rendered considerably paler. The sediment of black
vomit seemed more highly acid than the supernatant liquid — it makes a stronger
impression on the test-paper. The sediment acts as a ferment on liquids con-
taining sugar."

" The presence of ammonia in black vomit," according to Dr. B., " is uni-
versal, that is, it has always been found when looked for, and may be consi-
dered one of the tests of black vomit."

" During the former epidemic," Dr. B. informs us, " it was noticed in cases
of black vomit, that, when it preceded the yellow suffusion, the prospects of life
were improved'. The relations of this fact were not then understood. Black
vomit is significant of imminent danger, from the circumstance that it is the
dernier ressort of nature to relieve that contamination of the circulation which
has been produced chiefly by impairment of the function of the kidneys, and
the retention thereby within the system, of the worn-out nitrogenous elements
of the body and their poisonous metamorphoses. Now, if black vomit appear
early in the disease, before its march has extended to the great internal viscera $
before the bile function has been disturbed, or the urine rendered albuminous,
it ceases to be the significant symptom which has obtained so much ill-omened
celebrity. It is then the sign of a local, instead of a constitutional affection."

In the ensuing chapter we are presented with the observations of Dr. B., in
reference to the condition of the blood in yellow fever, as relates to the epi-
demic of which he treats. From these observations it appears that during the
first stage of the disease, in no instance could there be detected any really ab-
normal condition of colour, corpuscles, serum, or crassamentum, except some-
times the presence of bile. Changes of the blood were met with only in the
last stages, and after death. Cases, nevertheless, terminated fatally after
normal black vomit and hemorrhages, in which no unhealthy appearance of
blood after death could be observed, except as to the bile tinge. The appear-
ance of yellow fibrinous coagula in the heart was frequent after the worst
cases, and what may be termed the texture of the blood often remained good.
Blood passed off by stool, though of good crassitude and colour to the naked
eye, is always found under the microscope with all its corpuscles ruptured.
Which alteration Dr. B. considers to be, in great measure, due to chemical
changes which occur after its extravasation.

During life, however, the blood is sometimes found altered. This alteration
consisted chiefly in a change in the shape and condition of the corpuscles, and
a deterioration of the fibrin. The fibrin is sometimes greatly diminished in
quantity, at others, it seems to have lost, in a great measure, its power of fibril-
lation. The albuminous element appeared, by the rough test of its becoming
solid by heat to coagulation point, to be sufficient.

" The healthy condition of the blood in yellow fever," observes Dr. B.,
" seems associated with free action of the kidneys, or copious black vomit, and
alkaline exhalations of the breath. And the deterioration of the fibrin has
an obvious relation to the amount of free ammonia remaining in the circulation.
The changes in the shape of the corpuscles are probably due to alterations in
the density and saline constituents of the serum. The blood of the cadaver
in this epidemic, was in the vast majority of cases more or less ammoniacal."

In chapter 8, we are furnished with the observations of Dr. B. on the am-
moniacal breath of yellow fever patients. From these observations it became
apparent that the urea of the suppressed urine is eliminated from the system
as a volatile salt, by its metamorphosis into a carbonate of ammonia, which, as
such, is frequently found in the breath, occasionally in the black vomit and
hasmatemesis, almost always in the stool ; in two cases in the urine, always in
normal black vomit in combination with an acid, and, indeed, apparently per-
vading all the tissues of the body.

In the chapter on the sequelae of yellow fever, Dr. B. states that relapses

486

Bibliographical Notices.

[Oct.

were of frequent occurrence, occasioned most likely, in great measure, by a
return of the patient to the focus of infection after discharge from the hospital.
Those relapses, we are told, were almost exclusively among the aborted cases.
They frequently recurred, and were aborted several times. The primary
attack was generally, but not always, without albuminosity of urine, and fre-
quently the relapse also ; generally, however, in the relapse albuminous urine
was expected, even if the disease was again aborted, during convalescence.
Only two relapses occurred after the disease had run on to black vomit, both
of which were readily aborted, although in one the relapse proceeded to albu-
minous urine. The tendency to relapse or second attack was generally within
the first month after the primary attack.

Dr. B. describes four distinct varieties in the mode of death in uncompli-
cated yellow fever; and these are sometimes blended: namely, syncope,
uraemia, apoplexy, and asphyxia. Death from syncope may arise from exces-
sive discharges of black vomit, or from hemorrhage, as excessive epistaxis,
bleeding from the mouth and gums, or from the black vomit and hemorrhage
combined. If before death the urine be suppressed, and the black vomit is
not copious or has ceased, the circulation becomes contaminated, and when
this condition acts upon the brain in its mildest form, the effect is not unlike
alcoholic inebriation. In one case the patient, on the night of his death, sat
up in bed, drank beverages, and joked with the shipmasters around him ; in
another, the patient, within a few hours of his death, was found sitting up in
his chair, and regaling himself with his tobacco pipe. If all the excretions
and secretions be locked up, as occasionally happens, the symptoms of ursemic
poisoning become more violent, the sensorium painfully affected, irritability of
temper, screams, and wild ravings ensue, followed by convulsions, coma, and
death.

Death by apoplexy, caused by congestion and extravasation of blood on the
brain, was observed in several cases. In one case death from asphyxia was
the result of laryngeal suffocation, and in two, of pulmonary apoplexy.

We must pass by without notice the chapter on the path61ogical anatomy of
yellow fever, though replete with interest, and can only give the following con-
cluding paragraphs of the chapter on its diagnosis and prognosis.

"Yellow fever, although it may be engrafted on an intermittent, when once
formed, has no intermissions. It is a fever of one paroxysm, without the
crisis of perspiration, and when it is over, health is restored, or the disease
goes on inducing its ultimate changes without febrile action. The time of
seizure is different with yellow fever from that of our permanently endemic
fevers. It generally comes on in the night half of the twenty-four hours;
while with us, all our miasmatic fevers, whether quotidian, double quotidian,
or tertian, in the immense majority of instances, occurred at mid-day. And, if
we follow intermittent into its sequelae, we find no resemblance between the
two diseases. There is not the quick restoration of health usual in yellow
fever, nor the bloody furuncles of unhealthy convalescence, but, instead, en-
larged spleen, anaemia, dropsy, and colliquative dysentery."

" The number of the characteristic symptoms present, and the degree in
which they are manifested, furnish criteria of the severity of the case, and the
ratio of danger. A slow pulse and moderate temperature of the body, and
quiet stomach, are always favourable indications. But the more fiery crimson
the tip and edge of the tongue, the more irritable the stomach, the severer the
headache, the worse the prognosis of the first stage, and vice versa. Slight or
moderate epistaxis is a sign of little prognostic value in any stage ; but streaks
of blood in the early vomit, indicates much danger ; while the same, during
the stage of black vomit, or after acid elimination has set in, is favourable, if
the corpuscles are found entire. In the second stage, the earlier or more
complete the suppression of urine, and the more copious the ejection of black
vomit, the more imminent the danger. But if the urinary secretion continue,
and the black vomit be scanty from the first, or is afterwards suppressed, the
patient may yet survive. Urine simply albuminous is a less serious sign than
when it also contains tube casts ; but if these are thin and few in number,
they do not add much to the gravity of the indication. Free, copious urine, no

1857.]

Blair, Yellow Fever Epidemic of British Guiana.

487

matter how dark or bilious, is the most favourable of any single sign. If the
urine be scanty, and it be loaded with tube casts, entangled in epithelial and
fibrinous matter, forming a light buff coloured sediment, it indicates a complex
lesion of the secreting structure of the kidney. It is the urine symptom in
its maximum of severity, and is as fatal as if the suppression had already
occurred. Blood corpuscles in the urine were not looked on with apprehen-
sion. A faltering of the articulation is a bad prognostic, and a difficulty of
protruding the tongue enhances it." " The danger of the case is enhanced by
its inflammatory complications, and by hypertrophy of the heart. The recency
of residence in a temperate climate, the race or complexion of the individual;
the fact of his previously having suffered from a gravior attack, or an aborted
one, will enter into an estimate of his chances of recovery/'

In the ensuing chapter some of the points connected with the etiology of
yellow fever are discussed.

From the observation of the epidemic of 1852-53, it would appear, that,
although a certain high average temperature is required for the generation and
continued existence of the efficient cause of yellow fever, it has not its genesis
from any known combination of meteorological elements, and may appear at
a time when these are highly favourable to general health and comfort. It
would appear further, " that the laws of its diffusion differ from those of gases ;
that it is impelled by atmospheric currents, but seems to possess some power
of locomotion/' as indicated by its shifting lines of infection and gyratory
movements; "that the development of its power was gradual, from its feeble
and diluted manifestation at the end of October, till its perfectedness at the
end of December, and its maximum of intensity a month afterwards ; that
during the course of its progress it showed marked variations of epidemic
power ; that in constitutions apparently the same, the system was affected in
various degrees, as if the poison acted in proportion to its quantity, and as a
poison and not a ferment ; that its first impression on the system seemed in
many cases local and circumscribed, although attended with the usual consti-
tutional disturbance; that it can actively occupy the body simultaneously with
other affections, and may be either subordinate or paramount in the issue ; that
though the extensive application or saturation of the system by the efficient
cause eventuates in a spontaneous outbreak of the disease in the individual,
there are circumstances which accelerate its action and augment its intensity,
and others which retard or entirely .obviate and render it inert."

Previously to considering these two set of circumstances, Dr. B. considers
those facts which bear upon the question of contagion. Numerous observa-
tions are adduced in which the freest intercourse with the sick took place with-
out the occurrence in a single instance of the unquestionable propagation of the
disease ; one or two cases, however, are referred to, which, it is admitted, may
be open to suspicion, till all the circumstances in connection with them are
explained.

" I have," Dr. B. observes, " stated thus all the facts that have come to my
knowledge during the course of the epidemic, which favour the doctrine of the
personal transmissibility of yellow fever. They were earnestly looked for
among the countless opportunities for observation, and no others could be dis-
covered. Those which were found have been honestly declared. In such a
poverty of positive proof in the affirmative of the doctrine, it is no argument
against those who disbelieve in the doctrine of contagion, to assert that their
proofs amount to negative evidence only. The experience of the present epi-
demic has confirmed that of the past, and the idea of contagion, which was
then unanimously relinquished, has not been revived. Neither do facts counte-
nance the fanciful compromise which some have offered as a settlement of
what is scarcely a question among those who in modern times have seen the
disease with their own eyes, viz : that it is the type of disease in which black
vomit appears only which is contagious. In Demerara we would as soon think
of asserting that intermittent fever in some of its forms and types is contagious,
as to predicate it of any of the manifestations of yellow fever."

Among the causes which accelerate the action and augment the intensity of
the efficient cause of yellow fever, Dr. B. enumerates, heavy rains, with calms,

488

Bibliographical Notices.

[Oct.

creating a damp, hot, steamy atmosphere, or the prevalence of land winds,
which are cold, comparatively damp, and of low dynamic power. The return
of a dry, cool, clear, elastic atmosphere, with sweeping trade-winds from the
ocean, was always followed by mitigating effects. The rationale, Dr. B. re-
marks, is easy. The condition of the weather first referred to oppresses the
cutaneous and pulmonary functions, and thereby lowers the tone of health
and its power of resistance to the action of noxious agents, at the same time
that the stagnation of the air is favourable ,for the accumulation of the atmo-
spheric poison, whatever it may be.

The next predisposing and intensifying circumstance noticed is locality. In
the last as in the former epidemic, the poisonous agent persisted in its pre-
dilection for low, damp, crowded places, and the neighbourhood of putrid ex-
halations, and woe to the unwary or reckless who lived or lingered in such
places or exposed to such exhalations.

Fatigue and checked perspiration and long continued solar exposure also
tended to precipitate the attack. The tolerance of the poison which those resi-
dents who had passed through the epidemic from its first feeble manifestations,
had acquired, was seriously impaired by even a temporary removal from the
colony, and a return to it within a few weeks. The depressing emotions of the
mind were highly favourable to the action of the poison. "Worry and vexation,
crushing sorrow, panic, and even overwhelming joy, have each had its victims.
Among the exciting causes of yellow fever, Br. B. enumerates the presence in
the body of other febrile and irritating affections. A paroxysm of intermittent
fever, he remarks, would sometimes set the morbid train in motion, as also the
primary and secondary fever of smallpox, or an attack of pneumonia or even
bronchitis. The stench of bilge water seemed sometimes to be an exciting
cause.

" One of the most favouring causes of the action of yellow fever poison was,"
according to Dr. B., " infancy. The constitution of the new born or young
white Creole was highly susceptible. He or she was truly in the category of
new comers. Not only did the first cases in town occur in children, but they
followed numerously and repeatedly. As these infants and children were not
exposed to some of the physical and moral influences which favoured the at-
tack in adults, their high susceptibility can be imputed to structural differ-
ences only.

" Many facts," says Dr. B., "came to my knowledge, which showed that
family predisposition for yellow fever exists, and is evidenced under varieties
of exposure. It was noticed in several cases that a scorbutic diathesis, or
sponginess of gums in the individuals attacked, prognosticated the worst re-
sults. But the great predisposer — the pabulum on which the epidemic revelled
— was the organization of the white who had recently arrived from an elevated
or mountainous country beyond the tropics.

" On the other hand, in looking for the causes which operate in retarding,
or mitigating, or entirely shielding from the action of the yellow fever poison
in the infected localities, we find that cheerfulness of mind, active but not
laborious occupation, regularity of habits, and avoidance of night air, sustain
the tone of health and militate against the inroads of the prevailing disease.
The appearance of the eruption of smallpox seems to supersede the yellow
fever poison. The presence in the system of evacuant diseases, such as the
advanced stages of phthisis when the tubercles have softened, and even gonor-
rhoea, seems to have a retarding power. Several instances in the hospital were
observed of attacks supervening on the heading up of the discharging surfaces
of burns, scalds, and wounds.

" Of all the protections, that of complexion was paramount. "When the
ships' crews were disabled by sickness (and that was in the majority of in-
stances), their places were supplied by negro sailors and labourers. On board
of many vessels, black labour alone was to be seen employed, yet among those
labourers and stevedores a case of yellow fever was never seen." Of 7890 African
(black) immigrants, none contracted yellow fever.

We have already so far exceeded our limits in the notice of Dr. B's. report

1857.] Blair, Yellow Fever Epidemic of British Guiana.

489

that we can afford room for a brief outline only of the chapter on treat-
ment.

The primary object of treatment was, if possible, to abort the attack by the
administration of a mixture of calomel and quinine. Twenty grains of the
first, and twenty-four of the second, for an adult, given in some simple syrup
or pap. This dose was repeated at intervals of four or six hours, to the extent
of four doses, unless the attack was earlier arrested. If after three or four
doses are given the disease is not cut short, little room is left for active
interference on the part of the physician, although still much may be done
in putting the patient in the best condition for sustaining the struggle, and
keeping off intruding complications.

In preparing the irritable stomach for the reception of this abortive dose,
creasote, we are told, had often an admirable effect.

The first dose of the calomel and quinine was followed by a suitable dose of
a purgative mixture, composed of drachms ij of carbonate of magnesia with oz.
ij of sulphate of magnesia, in oz. viij of peppermint-water.

The aborting dose of calomel and quinine should be used as early as possi-
ble in the attack. "When a state of apyrexia is induced, it may be relin-
quished, the end is attained ; but if the urine has become coagulable, or the
epithelium of the tongue has begun to peel, it is of no use pushing it further,
the time for its use is passed, and subsequent to this it will be a noxious irri-
tant.

" Sometimes the disease is incompletely aborted, that is, although it does
not proceed to the second stage, a certain amount of febrile action still continues
after the resolvent has been pushed to a reasonable extent. It was the prac-
tice then to give half an ounce of camphor water and spirit of mindererus
every three or four hours, till the skin became cool and soft. Should, however,
the stage of acid elimination supervene, this medicine is stopped, and small
doses of bicarbonate of soda and nitre (five to ten grs. of each) substituted."

When the mucous surfaces, as indicated by the tongue, were denuded of
epithelium, the use of gum-water was decidedly beneficial. It lubricated,
defended, and soothed the raw surfaces. The strength was generally three
drachms of the purest powdered gum dissolved in six ounces of cold water ; a
tablespoonful being given every hour or two. For thirty-six or forty-eight
hours of the most critical period of the disease, it is used without dissatisfac-
tion on the part of the patient ; after that it can be substituted by, or alternated
with, arrowroot pap.

" When the heat of surface was ardent, the wet sheet or blanket was used for
the reduction of temperature by evaporation, with frequently very good effect.
But in the late stages of the disease, when the skin was cool or cold, the patient
seemed to have an instinctive craving for its reapplication, and frequently
asked to be put into it. There would appear to be two causes for this feeling.
We find it to exist in cases in which black vomit has been copious, and the
associated thirst distressing; also where there has been no black vomit of any
consequence, and the breath is highly ammoniacal. In the former case the
stomach ceases to be an absorbing viscus in anything like the proportion of its
secretions and transudations. The skin is therefore employed in reducing the
crasis of the blood by the absorption of water, as shipwrecked mariners are
said to quench their thirst. But not only does the skin afford an inlet for the
imbibition of diluting fluids, but the softening of the cuticle would seem to.
afford an additional outlet for the noxious elements of the circulation, and it is
probable in this direction we must in future look for auxiliary means of re-
lieving the blood of its poisonous metamorphosed and effete constituents, the
onus of which is now thrown on such vital organs as the stomach and lungs.

" The food during the course of yellow fever should be of the blandest des-
cription ; chicken tea, arrowroot, sago and barley water constituting the chief
articles ; and these should be taken when the stomach is at all irritable, in
minute quantities at a time. This rule also applies to drinks of all kinds.
The patient is greedy for a large draught of fluids, but by sucking them through
a glass tube of small bore, or taking them by the tea or tablespoonful, they are
much more likely to be retained. A cold infusion of oatmeal was found an

490

Bibliographical Notices.

[Oct.

agreeable drink for the Scotch seamen, of which they did not seem to tire. A dis-
like of sweets was observed among the patients, and when lemonade was asked
for, the usual quantity of sugar was objected to. Tea was found uniformly to dis-
agree with the patients, and cause vomiting, particularly in the advanced stages.
Dilute alcoholic drinks were given freely, and with good effect."

During the course of the disease, auxiliary treatment was required to meet
contingent symptoms. Cupping, leeching, and blistering were found useful
in relieving the primary head symptoms and irritability of stomach, when ap-
plied respectively to the nape of the neck or epigastrium. Tenderness over
the liver seemed also benefited by these applications. Dr. B. has never seen
any benefit resulting from their application over the kidneys, with the view of
relieving that congestion of which albuminosity of the urine and suppression
are the indices.

" When the primary reaction was violent, and the face was turgid, and the
head symptoms severe, arteriotomy was performed and with benefit. In a few
such cases, and when the patient was young, .strong and full blooded, or
where the dynamic congestions were so violent that the vessels yielded to the
turgescence and impulse, and blood corpuscles without tube casts, or even but
a haze of albumen, was present in the urine, the arm was opened, and free
bleeding relieved the tension of the vascular system. In such cases conva-
lescence was slow and unsatisfactory, but the immediate results had been
beneficial.

" In general, the bowels responded easily to the action of mild purgatives ;
but a cluster of cases occurred about fifteen months after the commencement of
the epidemic in which croton oil was required to follow the resolvent doses.
Hydrocyanic acid was supposed beneficial in a few cases in abating primary
irritability of the stomach, and being easily taken, may be borne in mind by
the practitioner, as a variety of such resources are at times required. Ether
was frequently attended with marked advantage in removing or abating the
distressing symptom, hiccup, but it was also used as a diffusible stimulant, and
when acceptable to the patient, is fully equal to brandy for that purpose."

Dr. B. remarks, that of all the auxiliaries which must be occasionally im-
pressed into the service of the patient, by far the most important is morphine.
It should never be given, however, when there is suppression or tendency to
suppression of urine. Its beneficial effects are most visible and unqualified in
those cases wherein the disease has been imperfectly aborted, in which, after
a few doses of the aq. acet. amnion, and camphor water, it will induce a good
night's rest, out of which the patient awakes free from disease. The maximum
dose for an adult should never exceed eight drops of the solution of the acetate
(one-fourth of a grain) ; and this dose should rarely be repeated within twenty-
four hours. Morphine, we are told, is perfectly safe, while the urine is non-
albuminous.

" The ' smouldering form' of yellow fever," according to Dr. B., " is best
treated by rest, the recumbent position, cool drinks, and abstinence from any
but the lightest food. The patient, however, should be closely watched, although
interference is seldom required, the curative and conservative power of nature
being adequate to the perfect restoration of health in almost all these cases.
Inflammatory complications were treated on general principles ; and in pneu-
monia the tartrate of antimony was borne well."

We must close our imperfect notice of this most interesting report with Dr.
Blair's pathological definition of yellow fever.

" The proximate cause of yellow fever is an aerial poison which impinges
against the exposed mucous surfaces, and there excites in the contiguous capil-
laries a specific irritation which extends itself in a varying degree to the whole
capillary system. The chief anatomical results of this irritation are epithelial
desquamation, exfoliation of basement membrane, and textural lesion of the
capillary tubes, occasionally amounting to their entire disintegration. The
morbid phenomena, supplementary to the febrile reaction, are the compound
results of capillary congestion, extravasation, and hemorrhage, and of a circu-
lation contaminated by retained excretions." D. F. C.

1857.] Dunglison, General Therapeutics and Materia Mediea. 491

Art. XXY. — On some points in the Anatomy of the Liver of Man and Vertebrate
Animals, with Directions for injecting the Hepatic Ducts, and making Prepara-
tions. By Lionel S. Beale, M. D., London. Illustrated with upwards of
60 photographs of the author's drawings. London, John Churchill, 1856 :
pp. 80, 8vo.

Since Mr. Kiernan, of London, gave the first satisfactory account of the
intimate structure of the liver, in 1833, most of the living anatomists have
investigated this subject. Nearly all agree as to the arrangement of the coarser
structural elements, and the relative position of the different systems of vessels
and the hepatic ducts ; but opinion is much divided in regard to the exact
arrangement, of the secreting structure within the lobules of the organ.

Most authorities, including Henle, Handfield Jones, Hassall, Guillot, Kb'lliker,
Hyrtl, Gerlach, and Carpenter, adopt the view that the bile secreting cells
occupy the meshes of the intra-lobular vascular plexus, or in other words form
an intertexture with the latter ; some considering the rete of cells as a solid
one, as Handfield Jones, and Kb'lliker, others describing intercellular passages
for the escape of the bile, as Henle, Gerlach, and Guillot. From this intra-
lobular plexus t)f bile-secreting cells, the hepatic ducts have their commence-
ment, lined with epithelial cells, much smaller than the former cells.

Other authorities, including Krukenberg, Theile, Van der Kolk, Backer,
Leidy, Retzius, Weber, and Lereboullet, adopt the view that the bile-secreting
cells are contained within an intra-lobular plexus of tubes of basement mem-
brane, from which the smaller hepatic ducts have their origin.

Dr. Beale, in the work above indicated, presents the results of his investiga-
tions into the intimate structure of the liver of vertebrated animals ; and his
observations and experiments bear the stamp of care and accuracy. After
many experiments he has succeeded in making good injections of the hepatic
ducts and the intra-lobular plexuses continuous with them, as was previously
done by Berr.es, Hyrtl, Retzius, and others.

Dr. Beale's observations support the view that the bile-secreting cells are
contained within tubes of basement membrane, about the j^of^ °f an incn iQ
diameter, and constituting the intra-lobular biliary plexus of Mr. Kiernan,
within which originate the commencement of the hepatic ducts, which are not
more than one-third the diameter of the biliary tubes.

The sacculi imbedded in the parietes of the larger hepatic ducts, usually
considered to be mucus follicular glands, Dr. B. has discovered frequently
to communicate with one another, and he considers them to be diverticula or
minute gall-bladders.

The plates accompanying the work are photographic illustrations from the
original drawings of the author. J. L.

Art. XXVI. — General Therapeutics and Materia Medica: adapted for a Medi-
cal Text Book. With Indices of Remedies, and of Diseases and their Remedies,
By Robley Dunglison, M. D., LL. D., Professor of Institutes of Medicine,
etc., in Jefferson Medical College of Philadelphia, etc. etc. With one hundred
and ninety-three illustrations. Sixth edition, revised and improved. 2 vols.
8vo. pp. 544, 539. Blanchard and Lea, Philadelphia.

A critical review of a work which, like the one before us, has passed, within
comparatively few years, through six editions, would be a labour entirely un-
called for. As a guide to the medical student in the acquisition of the princi-
ples and more important details of general therapeutics and materia medica,
and at the same time, a trustworthy book of reference to the practitioner who
would learn the leading results of modern observation and reflection on any of

492

Bibliographical Notices.

[Oct.

the subjects of which it treats, the treatise of Dr. Dunglison could never have
sustained its place amid the many contemporary treatises on the same branches
of medical science, by authoritative writers, as well European as American, had
it not been found in the main correct in its teachings, sufficiently copious as an
elementary work, and withal clearly and skilfully arranged.

The work is too well known, and too correctly appreciated by those for whose
use it was intended, to render any analysis of its contents necessary ; we need
only remark that in the present edition it has undergone a thorough and care-
ful revision, while every new fact has been incorporated in it, so as to render
it a faithful epitome of the actual knowledge of the profession on the branches
of which it treats. " D. F. C.

Art. XXVII. — Researches into the Structure and Physiology of the Kidney. By
C. E. Isaacs, M. D., Demonstrator of Anatomy in the University, of the city
of New York.

On the Functions of the Malpighian Bodies of the Kidney. By C. E. Isaacs,
M. D., etc. New York, 1857.

" Researches into the Structure and Physiology of the Kidney," and " On the
Function of the Malpighian Bodies of the Kidney," are the titles of two excel-
lent memoirs by Dr. C. E. Isaacs, of New York, published in the Transactions
of the New York Academy of Medicine. In these, Dr. Isaacs gives the results
of a series of laborious and carefully made researches into the intimate struc-
ture and function of the kidney. In relation to the structure, his investigations
generally confirm those of Miiller, Bowman, Kolliker, and the later ones of
Hyrtl, Gerlach, Leydig, and others. In opposition to Bowman, he agrees with
Kolliker, Gerlach, and Leydig, in considering the Malpighian bodies as not
only inclosed within the dilated extremities of the uriniferous tubules, but also
to be invested with a distinct layer of cells. From numerous experiments per-
formed on living animals, Dr. Isaacs attributes the principal agency in the
secretion of the constituents of the urine to the Malpighian bodies, in opposi-
tion to the view of Bowman, and most physiologists, who consider that they
merely separate the aqueous portion of the urine from the blood. J. L.

Art. XXVIII. — On the Extent of the Pleura above the Clavicle. By C. E.
Isaacs, M. D., Demonstrator of Anatomy, etc.

This is the title of another excellent paper by the same author as the pre-
ceding, and likewise published in the same work. Dr. Isaacs has most indus-
triously and carefully collected 100 cases in which he has ascertained the rela-
tive position of the pleura to the clavicle. As the result of these examinations
Dr. Isaacs observes : —

" It has thus been shown that, in 100 cases, the pleura rose only to the upper
margin of the clavicle, or very slightly above it, in 5 instances ; that in 11
cases the right pleural sac extended across and to the left of the median line,
making an average width of the pleura, at this point, of four inches ; that a
similar arrangement never was observed on the left side; that in 23 cases the
pleura ran high, extending two inches and upwards above the clavicle, thus
giving an average proportion of one in four; that in 14 instances this occurred
on the right side, and in only 5 cases on the left, and on both sides in 4 ; that
in one case only, the pleura attained the height of two and a half inches above
the clavicle ; and that the height and width of the pleura are both greater in
the male than in the female. These facts, then, are of value to the physician,
because the apex of the lungs corresponds with the concavity of the pleural
sac above the clavicle, and it is important for him to ascertain its extent, if
practicable, by auscultation and percussion. They are also useful to the surgeon,
in the removal of tumours, and in other operations in this region." J. L.

1857.]

493

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES

IN THE

MEDICAL SCIENCES.

ANATOMY AND PHYSIOLOGY.

1. Anatomy of the Supra-Renal Capsules. — The observations of Addison in
regard to disease of the supra-renal capsules, and the investigations of Dr.
Brown-Sequard in regard to their importance in the system, have invested
these bodies with so much interest that the following remarks by Prof. Ludovic
Hirschfield on their anatomy will be regarded as important : —

" Fixed solidity by numerous vascular and nervous prolongations to the
inferior cava, to the aorta, to the renal and inferior diaphragmatic vessels, to
the solar, renal, and diaphragmatic plexuses, the supra-renal capsules have no
direct communication with the kidney, except by very thin areolar tissue.
They never follow the displaced position of the kidneys. In new-born children
they are so intimately connected with the kidneys that they appear to be a
constituent part of the same. The volume of the capsule depends upon the
age, being larger than the kidneys during embryonic life, almost as large as
these organs in young children ; far from increasing with age as the other
organs, they rather diminish, so as to be only the twentieth or thirtieth part
of the size of the kidneys. Variable in different subjects, their size is not the
same with every adult, nor with old people, and their volume is not more con-
siderable in the negro race than in the white race, as observation has many
times shown. M. Cruveilhier mentions having found them voluminous in
several aged women.

Considered as to their dimensions, they differ on the right and on the left.
The left capsule has from 32 to 36 millimetres1 in length, by 26 to 28 in
breadth, that on the right side from 29 to 31 in length by 26 to 28 in breadth ;
their thickness towards the centre is from 3 to 5 millimetres. The weight,
likewise, is not the same for each ; sometimes the capsule of the right side is
heavier than that of the left; at other times it is the contrary; on an average,
however, it is from 4 to 5 grammes.2

In order to study the supra-renal capsules, anatomists distinguish two sur-
faces for each — the one anterior, the other posterior ; and two borders — the one
superior, the other inferior. The anterior surface presents near its middle part
a groove, more or less transverse, destined to contain the largest of the capsular
veins (the middle capsular). On the right side, the capsule is found behind
the first curve of the duodenum, and in a depression on the posterior part of
the inferior surface of the liver. On the left, it is situated behind the spleen,
and the tail of the pancreas. The posterior surface, smaller than the anterior,
corresponds on both sides to the semilunar ganglion and to the diaphragm.
The inferior border or base, large and excavated, is moulded to the convexity

''One line English — 2.1166 millimetres French.
2 One gramme French = 15.438 grains troy English.

494

Progress of the Medical Sciences.

[Oct.

of the superior extremity of the kidney, to which it adheres by loose adipose
tissue. The superior border, sometimes curved, sometimes straight, at other
times semilunar, is applied to the liver on the right, and to the spleen on the
left side. In making a section of the supra-renal capsule from the inferior to
the superior border, one appears to find a triangular cavity of a darker colour
than the external surface, from the inferior part of which arises a small oblong
crest. This cavity is only illusive, and results probably from the separation of
the anterior and posterior walls after a previous rupture of the loose and deli-
cate cellular tissue which united them, or, perhaps, as M. Rayer remarked, from
the extravasation of blood following the rupture of the capsular veins. These
contiguous surfaces are bathed in a humour, the consistence and colour of
which vary with the subjects ; of a dark hue in the adult, it is reddish and
more abundant in the foetus.

Structure. — There is in the composition of each capsule an enveloping mem-
brane and a special tissue. 1. The enveloping membrane is formed of cellular
tissue, mixed with elastic fibres. Its superficial surface is surrounded by a
cellular fatty tissue, to which it is adherent by fibro-vascular prolongations ;
its deep surface sends into the substance of the body a multitude of prolonga-
tions, which divide it into numerous segments. 2. The substance proper, or
parenchyma, is composed of two substances, juxtaposed, but quite distinct
one from the other; one, external, is called the cortical substance; the other,
internal, is called medullary substance.

(A.) Cortical substance, yellowish, and of rather firm consistence, with an
average thickness of 2 millimetres. This thickness is divided into a considera-
ble number of cavities by very thin lamellae, united, and constituting a mass of
conjunctive tissue, which enters into the composition of the cortical substance.
Each cavity has a vertical direction in the substance, and a breadth which
varies from 0.35 to 0.5 mil., and which is observed even to increase to 0.7 mil.

Some anatomists have found in these cavities utricles, each of which has an
amorphous membrane, inclosing a substance of a granular nature, with which
nuclei and cells are blended. According to Kolika, the cavities contain poly-
gonal cells, from 0.14 to 0.27 mil., independent of each other, on both sides of
the cortical substance, and united into cylindrical masses in the middle of this
substance. Contrary to the opinion of D'Ecker, this same anatomist maintains
that true utricles are found only in the internal portions, where they present
themselves under a spherical or ovoid form, having a diameter from 0.5 to 0.7
mil., and containing masses of granular fat. The yellowish colour presented
by the cortical substance is in consequence of the cells being entirely filled
with granular fat, which gives them a great resemblance to the cells of the
liver in a pathological state. These fatty granulations are added to the con-
tents of the cells, formed in the normal state of minute granulations of a
nitrogenized nature. In the deepest stratum of the cortical substance, that
which borders on the medullary substance, and which is more coloured, are
found vesicles containing pigment granules of a brown colour. (B.) Medul-
lary substance. It is less solid, and has only a third of the thickness of the
cortical substance. From its centre arises the middle capsular vein, and
throughout its extent there is found a great number of nerves and vessels,
principally veins, which explains its deep colour and spongy aspect. By de-
composition, it changes quickly into a brown pulp, incorporated with blood ;
it is, therefore, necessary to study it immediately after death. It appears then
under the form of thin lamelhe of cellular tissue, which are continuous with
the septum of the cortical substance, forming a network of rounded and
narrow meshes. One finds in this network a delicate granular substance,
which contains pale cells of a diameter from 00.18 to 00.35 mil.

It contains some few fatty and pigmentary granules with nuclei and nucleoli.
These pale cells have the appearance of ganglionic corpuscles, and remind one,
to a certain extent, of the cells of the nervous system ; but they cannot be con-
founded. The capsular bloodvessels, the capsular arteries, very numerous and
variable in number, emanate from three sources, and are divided into superior,
middle, and inferior. The superior capsular arteries arise from the inferior
diaphragmatic arteries ; they are very numerous and small, and reach the

1857.]

Anatomy and Physiology.

495

superior part of the capsule, in which they are lost. The middle capsular,
larger and less numerous, sometimes even single, arise directly from the aorta,
and are distributed to the anterior and posterior parts of the capsule. The
inferior capsular arteries come from the renal artery. All the capsular arteries
anastomose freely with each other, being lost on the surface of the capsule.

The capsular veins do not vary generally so much as the corresponding
arteries, their number being nearly always the same. On each side is found
oftentimes a principal vein, the middle capsular, the size of which, especially
on the right side, equals almost that of the external jugular vein. These veins,
remarkable by their calibre, and by the absence of valves, course along the
groove on the anterior surface of the capsules, and, having received in their
course the ramifications proper to the capsule, some fine branches from the
surrounding fat, and the inferior diaphragmatic branches, empty themselves,
the right usually into the inferior cava, immediately under the liver ; and the
left, taking a longer course, opens into the corresponding renal vein. Inde-
pendent of these principal veins, the supra-renal capsules have other venous
branches, very fine and variable in number ; they are the superior and inferior
capsular. The former empty themselves into the diaphragmatic veins, the
latter into the renal veins ; it is not as yet shown positively that the capsular
veins have no direct communication with the interior of the capsules, as has
been maintained by some anatomists. The lymphatic vessels of the capsule
are proportionately voluminous : some are superficial, others deep ; those of
the right side lead to the lymphatic glands, which are disseminated around
the inferior vena cava; those of the left side conduct to the glands placed in
front of the corresponding pillar of the diaphragm.

The capsular nerves, very numerous and small, arise like the capsular arte-
ries from three sources, and are distinguished into superior, middle, and
inferior. The superior come from the diaphragmatic plexus; the middle,
more numerous, spring directly from the semilunar ganglia, and from the
solar plexus ; while the inferior are provided by the renal plexus. Bergmann
mentions having seen nerves springing out from the semilunar ganglion, cross
the border of the capsule, and return to the semilunar ganglion so as to form
in their course small loops.

I have sought for this latter anatomical arrangement, but have never suc-
ceeded in finding it." — Med. Times and Gaz., July 18, 1857.

2. Fibrin, its Nature and the Cause of its Coagulation. — "Regarding the nature
and origin of fibrin, Zimmermann repeats that he considers it as an excremen-
titious substance, exhibiting a certain stage in the metamorphosis of protein-
aceous bodies, not any longer fit to serve in the nutrition of the organism. A
small quantity of fibrin is regarded as a necessary constituent of the blood,
but "the healthier the subject, the smaller the quantity of fibrin." By further
oxidation, fibrin is, in the normal state, transformed into other excrementitious
circumstances. " Sometimes, however," the author says, " the formation of
fibrin takes place in so tumultuous and rapid a manner, that the transformation
into excrementitious substances cannot take place; whence arises exudation
of the accumulated fibrin, a process through which the blood is, for the time,
purified of this substance. Later, when the cause for this abnormal crisis has
ceased, the fibrin may again be absorbed and otherwise excreted. Such is the
case in pleuritis, pneumonia, &c." (p. 181).

The coagulation is caused, according to Zimmermann, by the commencement
of decomposition or putrescence; it is accelerated by the addition of substances
in the state of transposition of elements, as pus or ichorous fluid from gan-
grenous wounds (Nasse), in the whole by all influences favouring putrescence ;
it is retarded, on the contrary, by such influences as retard or prevent decom-
position. The putrescence causing the coagulation of fibrin does not take place
in the fibrin itself, but in other constituents of the blood, and principally in the
red blood-globules. The chemical constitution of the fibrin passing into the
solid state is regarded as remaining unchanged, with the exception of trans-
position of its atoms, effected by the contact with a substance in the state of
decomposition, analogous to the transformation of casein by the action of ren-

496

Progress of the Medical Sciences.

[Oct.

net. — Brit, and For. Med.-Chir. Review, July, 1857, from MoleschoW s Untersuch-
ungen zur Naturlehre, 1856.

3. Assimilation of different Oleaginous Substances. — The fact that some fatty
substances, when eaten, are almost entirely excreted by the alvine dejections,
■while the amount of fat in the feces does not become increased by the moderate
consumption of other fats, led Berthe to the examination of the quantity of fat
excreted with the feces under the influence of various oleaginous matters admi-
nistered to the same healthy subject in doses of from thirty to sixty grammes
per diem. These experiments led the author to the inference that there is
a point of saturation of the body for most of the fatty matters, from whence
almost the whole amount of fat ingested passes unassimilated through the in-
testinal canal. This point is arrived at after about twelve days with olive and
almond oil, and almost all vegetable oils ; after about a month with butter,
whale oil, and English purified cod-liver oil (huiles de baleine et defoie de morue
Anglaise, decolorees ou lavees) ; while the use of the pure brown cod-liver oil
(huile de foie de morue brum et pure) did not lead to an increase of fat in the
feces, even when its use had been continued for more than a month. Berthe,
therefore, proposes a division of the fatty substances into three groups: 1. Sub-
stances of difficult assimilation (olive, almond oil, &c.) ; 2. Assimilable sub-
stances (butter, whale oil, English cod-liver oil, and probably all animal fats) ;
3. Very assimilable substances (brown and pure cod-liver oil). — Brit, and For.
Med.-Chir. Review, July, 1857, from U Union M6d., No. 62, 1856.

4. On certain Physiological Phenomena connected with Parturition and Lac-
tation in Bitches that have not been Fecundated when in Heat. — Delafond directs
the attention of the Imperial Academy of Medicine to several phenomena de-
serving further examination. He corroborates the observation made already by
the great Harvey on doe-rabbits, and by Buffon on bitches, that the breasts of
animals which have not been fecundated when in heat sometimes become tur-
gescent, and secrete milk at the time when the parturition would take place if
the animals had become pregnant. The author observed the commencement
of the turgescence in bitches already two or three weeks before the term of the
pregnancy would have elapsed. In addition to this, the author witnessed,
at the period when the parturition would have occurred, enlargement and
swelling of the vulva, and increased viscous secretion of the mucous membrane
of the vagina; he even saw the animal in a restless state arranging a resting-
place, as if for an expected process of whelping; a few days later he discovered
the symptoms of milk-fever, and the bitch in this state allowed a puppy placed
underneath her to suck her breast ; she bestowed on it the same signs of affection
as if it had been her own, and the young animal was evidently thriving by the
nourishment it thus received. Leblanc, Roche, and Moreau, who took part in
the discussion on the subject, related observations of their own of a similar
nature, and Roche mentioned that Dubois had met with analogous phenomena
in women. — Brit, and For. Med.-Chir. Review, July, 1857, from I! Union M6d.,
No. 61, 1857.

5. Erectile Apparatus of the Eye. — Dr. C. Rouget, in a paper read before the
Academy of Sciences [Archives G6n., No. 3, 1856), brings forward new facts
regarding the elementary structure of these parts. He refers to the eyes of
birds, the principal mammals, and man. At the adherent border of the ciliary
processes he describes a layer of bundles, which is the layer of circular fibres
of the ciliary muscle. This in birds is formed, in front, of transversely-striped
fibres; behind, of regular fibres, rounded, refracting, and analogous to the
fibres of yellow elastic tissue, but containing here and there fine and regular
transverse stripes. In mammals the circular layer is formed of bundles of
dartoid fibre, smooth, and containing elongated nuclei, in the midst of which
run plexiform divisions of ciliary nerves. Outside the annular ciliary muscle,
in a kind of stroma of the choroid at the posterior edge of the ciliary region,
are bundles of radiated ciliary muscle. These bundles, formed in birds of
striated fibres, compose at least two muscular plains ; one, external and poste-

1857.]

Materia Medica and Pharmacy.

497

rior, is inserted after a short course into the posterior region of the bony ring
of the sclerotic : the other, covered at its origin in the choroid by the former,
is prolonged anteriorly as far as the anterior margin of the bony ring where a
portion of the fibres are inserted; whilst the remainder is attached to the
membrane of Descemet, the true elastic tendon of the anterior plain of radiated
muscular fibre. This is the muscle described by Crampton and others, who,
according to Rouget, were deceived as to its origin and true meaning. The
muscular apparatus of the iris is only the continuation of the deep plain of the
ciliary muscle (circular fibres). In birds, the transversely striated bundles
enter the iris obliquely, and, keeping in the course of this membrane a gene-
rally circular direction, cross each other more or less obliquely. In man, and
most mammalia, the same disposition obtains as in that of the iris of birds.
At the anterior edge of the ciliary muscle, the bundles of the deep layer of
this muscle, continuing their direction obliquely transverse, penetrate the iris;
and then, covering the external surface of this membrane, and entangling the
vessels in their meshes, they cross each other more or less regularly, arrive at
the edge of the pupil, and form the ring of circular fibres at the surface of the
iris, the sphincters. The author then speaks at length of the mechanism of
the parts, and of the functions they play in adapting the lens to vision, show-
ing how the contractions of the circular bundles of ciliary muscle force the
blood returning, from the iris into the ciliary folds, which, by compression,
affect the convexity of the lens.

MATERIA MEDICA AND PHARMACY.

6. Employment of Amylene. — M. Robert recently read, at the Academy of
Medicine, an interesting report of a commission, composed of MM. Malgaigne,
Velpeau, and himself, upon a memoir on amylene, submitted to the Academy
by M. Debout. The report states that M. Debout's paper offers nothing new
upon the subject, but confirms the observations already published by Snow,
Giraldes, and Tourdes, establishing that amylene produces anaesthesia very
speedily, without causing any painful sensation, or inducing that desire to
cough, or expectorate, so often observed in the employment of chloroform.
"During the entire procedure, " says M. Debout, "the pulse remains large,
full, and very rapid, the respiratory movements are deep, the skin warm, the
face highly coloured. In one word, there is an absence of those signs which
indicate that the new agent can readily exert any effect upon the phenomena
of organic life."

The reporter, in order to judge of this favourable account of amylene, made
a number of trials with it himself, employing Charriere's apparatus, which, by
covering both nose and mouth, prevents a loss of the vapour. One of the
remarkable properties of amylene being its slight solubility in the blood, its
vapour must be breathed in as concentrated a manner, and as continuously as
possible, under the risk of failing to produce insensibility, or of this being of
too short duration. M. Robert believes that is the want of observing this pre-
caution, and from merely administering it on a sponge, that some surgeons
have failed altogether, or have had to employ very large quantities of amylene.
He has employed it in 44 adults of both sexes. Most of the operations were
but of short duration, such as opening abscesses or panaris, avulsion of nails,
or amputation of toes ; but some have been of a more important character, such
as amputation of the thigh and arm, removal of the breast and of the parotid
gland, and extraction of a calculus from the prostatic portion of the urethra,
this last requiring a quarter of an hour. In none of these cases was any irri-
tation of the mucous membrane produced. Most of them were rendered insen-
sible in two or three minutes, a few not until six or seven ; while in three, after
ten or twelve minutes' inhalation had been tried in vain, chloroform had to be
resorted to. The agitation which so frequently precedes the action of chloro-
No. LXVIIL— Oct. 1857. 83

498

Progress of the Medical Sciences.

[Oct.

form was not observed. The countenance became more and more flushed. The
eyelids remained widely open, and the fixed eyes were frequently carried up-
wards, beneath the upper lid. The head was thrown backwards, and some-
times the limbs became extended and stiffened. The pulse very rapid, and, in
one case, its intermittent and filiform character excited alarm. Respiration
continued free, and the spasmodic closure of the jaws, with threatened suffoca-
tion, sometimes observed under chloroform, was never met with. It is an im-
portant fact, that amylene never gives rise to muscular resolution, and the
insensibility it induces is of very short duration, unless the application be con-
stantly repeated. After the operation, the restoration is rapid, the patient not
continuing to suffer any uneasiness. Two young girls, however, exhibited a
singular form of delirium, accompanied by sobbing and violent convulsive
movements. One of them, subjected some time after to chloroform, exhibited
the same symptoms. Thus, while amylene resembles ether and chloroform in
its power of preventing pain, it differs from them in the rapidity and tempo-
rary duration of its action, and in not exerting any power in muscular contract-
ility.

As to the question of danger, M. Robert observes that Dr. Snow's case has
proved that, as in the use of chloroform, death may take place in consequence
of a special predisposition of the economy of an unknown nature. The only
question really is, whether there is less danger attaching to the employment of
amylene. From various experiments he has performed upon animals, M.
Debout concludes that there is ; and he calculates that, if the dose of chloro-
form has to be doubled, to convert it from an angesthetic into a toxical agent,
that of ether has to be quadrupled, and that of amylene to be quintupled. The
reporter, having repeated the experiments upon birds and rabbits, believes that
this statement is accurate. Performing other experiments upon dogs, employ-
ing for that purpose a modification of Charriere's apparatus, he found that
chloroform gave rise to the usual series of symptoms, from simple insensibility
to complete muscular resolution, the animals always dying in the course of
thirty or forty minutes. Under the use of amylene, the same symptoms were
observed as in man, but a relaxation of the muscles was never attainable.
Moreover, continuing the experiment, with the intention of killing the animals,
these seemed to become habituated to its use, and recovered part of their sensi-
bility. The inhalation was terminated at the end of an hour, and the animals
soon began to walk, and were speedily restored. Having contrived an appa-
ratus by which large quantities of amylene could be breathed in a concentrated
form, the reporter at last succeeded in producing complete resolution of the
limbs, and death followed in twenty minutes. While these experiments show
that amylene is a much less powerful poisonous agent than chloroform, the
reporter does not agree with M. Debout that it may, therefore, be more safely
used in practice. It is, in fact, a leading point in the hisiory of anaesthetics,
that death has not supervened in man upon a successive and progressive evolu-
tion of the phenomena of intoxication, but that it occurs suddenly and unex-
pectedly, and in consequence of an unknown predisposition of the economy.

Amylene is, therefore, but another anaesthetic agent, to be placed side by
side with ether and chloroform. Its action is prompt and of short duration,
while its effects rapidly disappear. It is to be preferred in very short opera-
tions, when we wish simply to prevent or moderate the pain. Moreover, its
not exciting irritation of the air-passages renders it a valuable agent when
pulmonary lesions exist. It does not, too, give rise to vomiting or nausea, which
are not infrequent after chloroform. This is important, especially in relation
to children, enabling us to operate nearer their meal-time, and avoid the incon-
venience of submitting them to long fasting, which they support very badly :
nevertheless, vomiting does occur occasionally.

As the insensibility produced is of such short durability, and muscular con-
tractility is only exceptionally influenced by it, amylene should not be employed
for long and difficult operations, and especially those in which it is requisite to
subdue the contractility of the muscles, as in dislocations, hernia, the diagnosis
of abdominal tumours, etc. M. Tourcles has stated that muscular resolution
may at last be obtained by a sufficient prolongation of the anaesthesia ; but

1857.] Materia Medica and Pharmacy.

499

independently of the inconvenience that might result from the absorption of
such large quantities of amylene, and the troublesome uncertainty the surgeon
is kept in, respecting the return to consciousness of his patient, it is by no
means proved that such resolution would ensue upon a multiplication of the
doses. Moreover, the reporter's experiments would seem to show that such
repetition, providing the dose be not rendered excessive, tends to destroy the
activity of the agent; while, when resolution was obtained, it was only shortly
before death. — Bull, de Therap., May, p. 443.

M. Velpeau, as a member of the Committee, observed that he was no great
partisan of amylene, and does not think, so far as his own experience goes,
that it is likely to displace chloroform. Against its employment are its detest-
able smell, alike annoying to operator and patient, the little constancy of its
effects, and the necessity of employing an apparatus. As to chloroform, he
believes that the amount of danger attending its use has been grossly exagge-
rated. During the ten years he has employed it in from 5 to 6,000 cases, for
operations at different ages, and in both sexes, he has met with no accident
whatever. No important accident has, indeed, occurred at any of the great
Paris Hospitals. Moreover, how unjust, whenever a death occurs during or
after an operation, to attribute it to chloroform! Employed with precautions,
he does not regard it as a bit more dangerous than amylene, while it may be
administered without any apparatus.

M. Giraldes, at a subsequent meeting of the Academy [Gaz. Med., No. 21),
gave a further account of his experience, having used amylene in the cases of
seventy-nine children, varying from one to fourteen years of age, two drachms
being in most cases the quantity employed. The time required for the produc-
tion of the anaesthesia is usually about three minutes, but it varies much, both
in different persons and in the same individual. No ill consequence has
resulted, the anaesthesia taking place without reaction, or convulsions. In
eight cases, muscular rigidity was observed ; and when this occurs, the inhala-
tions should be suspended a while, and free respiration permitted. In six cases
vomiting occurred. The anaesthesia lasted for a very short time, but it may
continue for eight or ten minutes, and is easily kept up. Chloroform is a more
powerful agent, but it is also a more dangerous one. It may throw feeble chil-
dren into a state of cadaveric resolution; and the anaesthesia it induces is often
so prolonged as to endanger life. On other occasions it induces spasmodic
closure of the jaws, rigidity of the muscles of the neck and thorax, and all
the symptoms of asphyxia, rendering artificial respiration necessary. It gene-
rally gives rise to vomiting, or other signs of irritation of the digestive organs.
After the employment of amylene sensibility rapidly returns, and the children
seem in nowise to suffer from it. It may be given soon after meals, and to
enfeebled children, in whom chloroform would prove dangerous. It thus has,
like chloroform, its special indications, and frequently presents indubitable
advantages.

Dr. Kadlburger ( Wien Wbchenschrift, No. 19) relates the results of his expe-
rience of the employment of amylene in seventy-two cases of tooth-extraction,
he applying it by means of a sponge to both mouth and nostrils. He states
that the amylene he employs emits a smell of over-ripe pears, and is nowise
irritating to the respiratory organs. From one to one and a half minute inha-
lation suffices for this purpose. The falling of the uplifted arm, as if wearied,
is the signal for the discontinuance of the inhalation. No abnormal muscular
movements, or closure of the jaw were produced. The patient readily opened
the mouth upon being requested to do so ; and during the extraction, most per-
sons retained the consciousness of the application of the instruments. The
pain, when felt at all, was very slight, and never at all approaching to the tor-
ture attendant upon ordinary tooth-drawing.

7. Anaesthetic Action of Carbonic Oxide.- — Dr. Ozanam considers that the re-
sults hitherto obtained by the use of anaesthetic agents concur to demonstrate
the truth of the law that the whole series of carbonized bodies, volatile or
gaseous, are endowed with anaesthetic power, and that they possess this power

500

Progress of the Medical Sciences.

[Oct.

in proportion to the carbon which they contain. He has therefore undertaken
some experiments with carbonic oxide, carbonic acid, and cyanogen, and the
results observed with the first-named gas are detailed in the present memoir.

The carbonic oxide is obtained by the action of sulphuric acid, aided by
heat, upon oxalic acid ; when the latter is resolved into carbonic acid and car-
bonic oxide, and the carbonic acid is removed by lime-water, while the carbonic
oxide remains in the gaseous state. The experiments and observations were
thirty in number, of which twenty-five were on rabbits and five on man. The
author divides the phenomena produced by the inhalation of carbonic oxide
into four periods — viz : 1. The prodromic period; 2. The period of excitement;
3. The period of anaesthesia; 4. Death or restoration of sensibility.

A pipe connected with a bladder filled with carbonic oxide was introduced
into the mouth of a well-fed rabbit, whose nostrils were closed; an assistant
pressed upon the bladder, and the animal, forced to breathe by the mouth, in-
haled the gas mixed with atmospheric air. During the first five or six inspira-
tions the animal made no effort ; it was motionless and astonished, as if under
the impression of a danger which it suspected but did not know, and of which
it did not yet feel the violent effects. But at the end of fifteen to thirty seconds
this preliminary period was succeeded by a stage of excitement: the animal
leaped and made efforts to escape ; then these voluntary movements were suc-
ceeded by very strong convulsions, contractions, throwing the head backwards,
trembling, &c. During this period the circulation was accelerated at first from
fifteen to twenty pulsations under the influence of the convulsive agitation ;
then it returned to its normal rate, which it soon quitted and became slower.
The respiration, on the contrary, offered from the beginning a marked tendency
to become slower. To the convulsive state suddenly succeeded the period of
collapse or stupor; all movement ceased, the body fell back like an inert mass,
the head hung down, the eye was widely open, the pupil dilated, the sight
almost abolished, the four members were paralyzed, the urine passed involun-
tarily, the pulsation of the heart became more slow ; the respiration also was
less frequent.- If the inhalations are prolonged, the respiratory act is weak-
ened still more ; it occurs only about once in five or ten seconds, by a general
and jerking effort, resembling hiccough; but, prolonged to this degree, the
anaesthesia becomes dangerous, and it should be narrowly watched, for the
inspiratory nerves are almost paralyzed, and the animal approaches the state
of apparent death. j

The experiments made and recorded by Dr. Ozanam prove beyond a doubt
the anaesthetic action of the gas, and he regards it as more energetic in its
action than chloroform, but less prolonged in its operation; its effects are rapid,
violent, and transient, so that an animal may pass in a few minutes from the
state of apparent death to a normal condition. On the other hand, it possesses
certain advantages over chloroform, in the absence of a strcng, or penetrating,
or caustic smell — a circumstance which renders the gas easily respirable by
every person ; while ether, chloroform, and the carburets of hydrogen have all
a penetrating smell, which renders them offensive to many persons, and they
are caustic when applied to the skin. It is also easily measured, owing to its
permanently gaseous condition, which is not the case with chloroform and
ether: their volatility varies under the slightest influence, as the summer, the
heat of a room, or the vicinity of a stove, will cause a patient to absorb double
the quantity of the vapours which would have been breathed if the circum-
stances had been different. The anaesthetic" operation of carbonic oxide termi-
nates in recovery from insensibility, or in death. When the inhalations are
discontinued, the animal is abandoned to itself. During one to three minutes
the anaesthesia remains absolute, and the animal might be considered dead, if
auscultation did not still reveal the weakened sounds of the heart, and some
rare inspiratory efforts. The ordinary life soon recommences, respiration is re-
established, and the heart progressively resumes its normal rate, and sometimes
slightly exceeds it. But occasionally the passage from stupor or apparent
death to real death is sudden, unexpected, and similar in this respect to sudden
death by chloroform : the heart and respiration, already very slow in their
actions, cease at once and forever.

1857.]

Materia Medica and Pharmacy.

501

In case of poisoning by carbonic oxide, the antidote most likely to prove
serviceable is ammonia; and Dr. Ozanam details two cases of rabbits poisoned
by carbonic oxide, which were restored by the application of the vapour of
ammonia. — Brit, and For. Med.-Chir. Review, July, 1857, from Archives Ge'n.
de Mid., Feb. 1857.

8. On the Effect produced on the Circulation by the Long-continued Action of
Cold Water Externally. By Dr. H. Bence Jones and W. Howship Dickinson,
Esq. — Opportunities of making use of some douche and shower baths of more
than ordinary potency having presented themselves, the following experiments
were undertaken, with a view of removing some of the uncertainty which now
prevails regarding the effects of the outward application of cold water. These
experiments are divided into three sections: 1st, on the general effect of the
douche or shower-bath ; 2dly, on the effect of the shower-bath at different tem-
peratures ; 3dly, on the effect of the shower-bath in different circumstances.

Section 1. The first experiment was made by a douche-bath, by which 225
gallons of water were allowed to fall upon the head for a quarter of an hour.
By this the pulse was greatly relaxed in frequency and power, and it became
irregular; at one period of the experiment the reduction amounted to 30 beats
in the minute. The second experiment was made with a shower-bath deliver-
ing about 20 gallons of water a minute — upwards of 300 gallons in fifteen
minutes. The results were similar to those obtained with the douche-bath, but
were more marked. During the second minute, the pulse was found to be less
frequent by 40 beats than it had been previous to the fall of water ; and from
the fifth minute to the fifteenth, when the experiment terminated, it was ob-
served to be frequently intermitting and very weak. The third experiment was
made with a still more powerful shower-bath, at Vienna. This delivered nearly
38 gallons of water a minute — upwards of 550 gallons in fifteen minutes ; but
the openings in the rose were very fine, and the shower was much spread. In
the fourth minute the pulse was found to be imperceptible, and during the
remainder of the quarter of an hour for which the bath was continued it was
feeble and irregular. Afterwards the pulse was observed to be smaller and
rather slower than it had been previously, but it was immediately restored by
a warm bath. Thus it seems that a strong douche or shower-bath produces an
excessive immediate effect upon the pulse. By the first shock it may be reduced
in rate even 50 beats in the minute ; it then recovers a little, but after four or
five minutes, when the shivering commences, it again becomes reduced, and
often is rendered quite imperceptible.

Section 2. The experiments in this section were made for the purpose of
showing whether the effect varied with the temperature of the water. The
most interesting are two which were made with the powerful shower-bath
alluded to in Section 1, second experiment. In the first, the water was at 70°
Fahrenheit. The pulse did not fall in rate for three minutes, although it lost
much in strength and volume. When shivering commenced, at the end of the
fourth minute, the pulse was imperceptible, and it was scarcely to be felt until
the end of the sixth, and it remained weak and irregular until the termination
of the experiment at the end of the tenth minute. In the second experiment
the water was iced down to 50° F. The effect was much more rapid. During
the first fifteen seconds the pulse was reduced at the rate of 38 beats per
minute ; this was followed by a reaction better marked than before, and the
annihilation of the pulse, which followed the commencement of shivering, was
much more complete and of longer duration.

Section 3. Some of the effects observed to follow the use of the shower-bath,
taken under varying circumstances, are here stated. Two experiments were
made : one at the baths at Ischel, in Austria, and one at the Prussian bath, at
Vienna, where cold shower-baths were alternated with very hot vapour-baths.
It was found that the increased action of the pulse produced by the exposure
of the body to hot steam prevented that depression which would otherwise
have resulted from the cold water. A converse experiment is quoted from Dr.
Currie's " Medical Reports." An ague patient, who had derived advantage
from the cold effusion during the hot stage of the fit, nearly died from the

502

Progress of the Medical Sciences.

[Oct.

alarming depression which resulted from the same application while he was in
the cold stage.

The general conclusions are —

1. The usual effect of a strong douche or shower-bath is the immediate de-
pression of the pulse. By the first shock of water between 64° and 68° F. the
pulse becomes weak and irregular, and may be reduced in rate even fifty beats
in the minute. After the first shock the pulse recovers a little, but remains
weak until the secondary effect or showering comes on, when it becomes weaker
and intermitting, and may be quite imperceptible. After ten to fifteen minutes
the pulse remains very small and weak, and shivering continues whilst the ex-
periment lasts.

2. If the shower-bath is a small one (eight gallons), and the person taking it
in good health, no great difference is perceived in the pulse whether the water
is hot (110°) or warm (74° F.). If the water is very cold (47° F.) the pulse
becomes smaller, but the rate is not affected.

With a shower-bath giving twenty gallons per minute a difference of twenty
degrees (from 70° to 50° F.) causes a great difference in the shock. The differ-
ence in the after-effect, or shivering, is not so marked. The depression of the
pulse when the shivering comes on is more continuous with the colder water,
and is more manifest up to the end of the experiment.

3. When the pulse is raised above, or depressed below, its healthy standard,
the shower-bath or douche produces very much less or a much greater effect
than would be produced by the bath under ordinary circumstances.

As it seemed possible that a part of the reduction of the pulse might be due
to the action of the cold water upon the capillaries and the radial artery in
which the pulse was felt, a set of experiments were made in which the forearm
and hand were exposed to temperatures varying from 25° to 124° F. The results
of these experiments may be thus stated: —

1st. When one arm is in water at 50° and the other in air at 46° F., no differ-
ence in the pulse is observed in fifteen minutes.

2d. When one arm is in water at 110° and the other in air at 46° F., little if
any difference could be felt in the same time.

3d. When one arm is in water at 44° and the other in water at 107° F., there
was the same result in the same time.

4th. Even one arm at 33° and the other at 112° gave no result.

5th. Still lower and higher temperatures, 25° and 115° F., did not give any
decided result in fifteen minutes.

6th. The douche-bath on the arm and hand, at 42°, produced no greater effect
on the pulse than still water at 44° F.

Hence, generally, it follows, that no part of the effect produced by the
shower-bath on the pulse, depends on the action of the water on the hand and
forearm in which the pulse is felt. — Proceedings of Royal Med. and Chirurgical
Society, April 14, 1857.

9. The Bittera Pebrifuga as an Antiperiodic. — The practitioners of Martinique
having transmitted to Europe highly favourable accounts of the febrifuge quali-
ties of a plant found there, the Minister of Marine has directed that its efficacy
should be tested at the different naval hospitals ; and in this paper M. Delioux
furnishes an account of the results of the trials he has made of it at Brest. The
plant is one of the Rutacese, and has been termed bittera febrifuga, from the
English term " bitter-ash/'' by which it is popularly known at Martinique. Its
active principles are resident in a bitter resinoid, and in a bitter principle which
it is proposed to term bitterine, and which is very analogous, if not identical,
with quassit or quassine, obtained by Wiggers from quassia amara.

The bittera may be administered in the form of powder, infusion, or extract,
or the bitterine itself may be given in pills. The intense bitterness of the drug
disinclines some patients to it. M. Delioux has, as yet, only given it in the
form of extract, made into pills, administering from 10 to 15 grains, in divided
doses, during the pyrexia. This, he believes, is a better mode of giving this
and other bitter tonics used as succedanea to quinine, than prescribing them,
as in the case of quinine itself, in a large dose just before the paroxysm. Al

1857.]

Materia Medica and Pharmacy.

503

though declared in the Antilles to be an almost infallible febrifuge, sometimes
superior to quinine itself, M. Delioux believes it to be, in this respect, not only
much inferior to quinine, but also second even to arsenic — superior to the latter
though it be in the tonic power it exerts upon the digestive and general system.
After this, however, it should be ranked as one of the best succedanea ; and,
doubtless, as a good bitter tonic it is destined to play an important part in the
relief of many organic and functional debilitated conditions, and especially in
the anemic and cachectic states resulting from paludal intoxication. In a great
number of asthenic diseases, in anemia, in chlorosis, in convalescence from
fever, in exhaustion from hemorrhages or discharges, and whenever it is desired
to impart tone to the digestive and assimilatory powers, the bittera is indicated.
In some forms of gastralgia, as far as M. Delioux's experience has gone, he be-
lieves it will prove very useful. — Med. Times and Gaz., April 4, 1857, from Bull,
de Therap.

10. Therapeutic Employment of Cocoa-Niit Oil. By Dr. Pettenkofer. — For
some years past, cocoa-nut oil has been employed in the Munich Hospitals in
place of lard, as being far less liable to become rancid. It is especially suited
for frictions, as the warmth of the skin speedily renders it completely fluid and
absorbable, while lard remains unabsorbed, soiling the linen and clothes, and,
in spite of all cleanliness, giving rise to a rancid smell. Ointments of iodide
of potassium made with lard, even when quite fresh, speedily become more and
more yellow, pure iodine in place of the iodide being present. Made with
cocoa-nut oil, there is not the least change of appearance for two months or
more. The still frequent employment of butter in eye-salves might advantage-
ously be replaced by that of cocoa-nut oil. Various ointments, too, if prepared
with this, might be kept ready prepared in the shops, as they would not then
undergo the changes they do when made with lard. Moreover, this oil will
combine with a third more of water or other fluids than lard will, a matter of
importance for the combination of extracts and solutions of salts. It is of a
moderate price, usually of a very white colour, and possesses a peculiar smell,
which is not disagreeable to most persons. — Med. Times and Gaz., July 18,
from Buchner's Bepert., Bd. v.

11. Physiological Action of the Disidphate of Quinia. — Dr. H. Banke states
{Med. Times and Gaz., May 30, 1857) that he has found, as a uniform result of
five experiments which he has made on three healthy individuals, that the
disulphate of quinia diminishes the quantity of uric acid in the urine.

" The importance," he observes, " of this action of the drug, if it prove to be
constant, is obvious. Hitherto, our notions on the physiological action of
quinia have been exceedingly deficient, and so is our knowledge of the real
nature of ague, for which quinia is such an admirable remedy. Now, in ague
there is, according to all observers, a considerable increase of uric acid in the
urine, and, moreover, the spleen, the organ principally affected in ague, con-
tains, according to Scherer, normally, some uric acid. Is it not possible that,
by the study of the physiological action of quinia, we may in time be able to
throw some light even upon the nature of ague and the process of its cure ?

12. Pyrophosphate of Iron and Soda in Anosmia. — Messrs. Follet and Baume
call attention (Gazette Hebdomadaire de Med., May 20) to the advantages of tne
pyrophosphate of iron and soda as a remedy in anasmia, and the diseases of
which that condition is a symptom, or with which it is coincident. They state
that, in 1849, Dr. Leras presented to the Academy of Sciences a work on " The
Action of the Gastric Juice on the Preparations of Iron employed in Thera-
peutics ;" and that in 1855 he presented to the Academy of Medicine a memoir
in which he expressed the following opinions : —

" 1. The ferruginous preparations employed in therapeutics are all more or
less precipitated, or transformed into oxide of iron in the stomach.

"2. The pyrophosphate of iron and soda is an exception.

"3. This salt seems destined to take a place among the most efficacious
preparations of iron."

504

Progress of the 3Iedical Sciences.

[Oct.

Dr. Leras prevailed on several medical men to try on their patients a solu-
tion of pyrophosphate of iron and soda, prepared by himself, and the results have
just been published by Messrs. Follet and Baume in a "Report on the Clinical
Service at the Asylum of St. Athanasius during the year 1856." They say
that even in cases where there is no longer any hope of curing the mental
maladies, there may still be a means of retarding the physical decline, which
supervenes in almost all the patients in the same form, by a gradual failure of
general innervation — a decline which is shown frequently in the decomposition
of the blood, from which result those dropsies which are met with in all the
tissues. In such cases, all the efforts of medication ought to be directed to the
reconstitution of the blood, and when this result is obtained, it is not unfre-
quently seen that the system recommences its functions, a reaction in the
inverse direction of the disease sometimes taking place ; it is the prelude of an
unexpected cure.

Messrs. Follet and Baume know no tonics which act so promptly and
favourably as the pyrophosphate of iron and soda, prepared by M. Leras, in a
liquid form ; it is easy to administer, rapidly absorbed, and does not produce
fatigue to the digestive organs. They then give the particulars of seven cases
in which the medicine was tried during the year 1856 ; the results are cer-
tainly remarkable.

13. On fhe Preparation and Therapeutical Employment of Subcarbonate of
Bismuth. — The following is the mode of preparation of the subcarbonate of
bismuth described by M. Hannox, Professor at the University of Brussels.
The bismuth is first purified by melting this metal in powder with ten times its
weight of powdered nitre. After cooling, the metal is again powdered, and
mixed with ten times its weight of nitre, and after a second fusion the bismuth
may be considered as entirely free from the arseniurets and sulphurets which
it almost always contains. Then three parts of nitric acid are put into a retort,
and one part of pure bismuth is added. When the reaction is complete, about
a third of the liquid is evaporated, then the solution is poured drop by drop
into a solution of carbonate of soda, and a white precipitate is obtained, which
is subcarbonate of bismuth. The precipitate, after having been washed five or
six times with distilled water, is thrown upon a filter, and washed again to re-
move the last traces of carbonate of soda. It should be preserved in well-stopped
bottles. The physiological properties of the salts of bismuth are very little
known, for the simple reason that the subnitrate is the only salt which has been
employed in medicine. The operation even of this salt is not well understood,
as its insolubility offers an obstacle to the observation of the physiological phe-
nomena which might have been observed in the other salts of bismuth, such as
the citrate, the tartrate, the acetate, or the carbonate. It is also the insolubility
of the subnitrate which renders it inefficient in the greater part of the cases in
which it is indicated; and it also occasionally produces a very inconvenient
sensation of weight at the stomach. The subcarbonate is soluble in the gastric
juice, its action is rapid, it produces no sensation of weight at the stomach, it
rarely constipates, colours the stools less than the subnitrate, and may be em-
ployed for a long time without oppressing the stomach. The action of the sub-
carbonate appears to be sedative during the first days of its employment, and
subsequently to excite all the phenomena which result from the action of tonics.

As to its therapeutical action, it may be noted that all cases of gastralgia
consecutive upon phlegmasia of the digestive passages, cases in which the
tongue is red and pointed, and cases in which the digestion is laborious and
accompanied with putrid or acid eructations, or in which there is a tendency to
diarrhoea or spasmodic vomiting, demand the employment of the subcarbonate
of bismuth. This salt is also required in the vomiting of children, whether
caused by dentition or succeeding to frequent fits of indigestion, and in the
diarrhoea of weak children, especially when occurring at the time of weaning.
One great advantage possessed by the subcarbonate of bismuth is, that it neu-
tralizes the acids in excess which are found in the stomach. The subnitrate,
as is well known, fails always in this respect. In all the cases where the sub-
carbonate has been taken, the pain in the digestive passages is first found to

1857.]

Materia Med tea and Pharmacy.

505

disappear ; then the eructations cease, together with the vomiting or diarrhoea ;
the digestion becomes less and less laborious, the tongue gradually receives its
normal form and colour, and, if the use of the subcarbonate is continued, the
appetite increases from day to day, the yellow tint of the countenance disap-
pears, and the face becomes coloured at the same time as it ceases to be shri-
velled.

The subcarbonate of bismuth is perfectly insipid, and excites no repugnance.
It is given before meals. Adults take it in a little water, and children in honey.
It may also be made into lozenges. The dose for adults is from one to three
grammes, taken three times a day, in increasing doses. — Brit, and For. Med.-
Chir. Review, July, 1857, from Bull, de Therap., Feb. 15, 1857.

14. A New Principle of Colchicum autumnale. — M. Oberlin has just commu-
nicated to the Academy of Sciences at Paris some observations on the Colchi-
cum autumnale, from which he has extracted a neutral crystalline principle
which he calls colchice'ine, and which differs from colchicine, a complex and un-
crystallizable product. The properties of colchiceine are, to crystallize very
easily in pearly laminae, and to be almost completely insoluble in water, but to
communicate to this fluid a slight bitterness, which increases sensibly when it
is boiled. At this temperature a notable part of the product is dissolved, but
is deposited immediately after cooling. The solvents of colchiceine are alcohol,
ether, methylated spirit, and chloroform, which contract, when mixed with it,
a very intense and persistent bitterness. The alcoholic solution of colchiceine
is coloured by the addition of bichloride of platinum, but no precipitate is
formed. Pure concentrated nitric acid dissolves colchiceine, and becomes co-
loured of a very intense yellow tint, passing into a violet colour, then to a deep
red and a clear red, and finally returning to its primitive yellow colour. Con-
centrated sulphuric acid forms with it a solution of a very intense yellow colour,
which is preserved even when it is diluted with water, and brownish flocculi
are formed in it. Hydrochloric acid dissolves it with a clear yellow colour.
The acetic acid also dissolves it, but without change of colour. Colchiceine is
soluble in ammonia, and crystallizes by evaporation in the air ; and it dissolves
in caustic potash. It is unalterable in the air; it has no effect upon turmeric
paper or litmus paper ; exposed to heat, it first softens and afterwards fuses at
155° (Cent.?). The elementary composition of colchiceine is C62, 83+H6, 60+
m, 19+026,38=100, 00.— Ibid., from L' Union Med., Jan. 10, 1857.

15. Ether and CJiloroform Gelatinized. — Professor Rusponi has succeeded in
turning ether and chloroform into gelatine, by shaking them with white of egg
in a closed receiver. The compound obtained with the ether is semi-transpa-
rent: with the chloroform it is white and opaque. This gelatine is soluble in
water, and may be spread on linen in the form of a poultice. It will likewise
mix with morphine, cantharidine, conicine, &c, and may thus become of great
therapeutical use. — Lancet, August 8, 1857.

16. Manganese aim Potassa. — Mr. "Weeden Cooke [Lancet, Aug. 8) extols this
new preparation as a valuable caustic in cancer. " This caustic," he says, " con-
tains a very large quantity of oxygen, and would seem to act by imparting this
to the tissues, thus producing a chemical combustion. The pain produced is
much less than that of any other caustic, and in some instances after the first
minute or two there is no pain at all, and I have observed no after ill conse-
quences. This 'manganese cum potassa' caustic is a dark green powder, and
may be applied very readily by means of a small pepper castor. A thin coating
of it will remove instantly all unpleasant odour from the ulcer, and when used
for reducing the exuberant growth, must be applied in a layer as thick as the
tissue to be destroyed. By dropping a few drops of water upon the powder
after it is applied, it will form a paste, and adhere to the part, after which
simple dressing may be applied. By means of carrot poultices the eschar
drops off in three or four days. If necessary, the manganese is reapplied in
the same easy way until the diseased mass is all destroyed, and the subjacent
healthy tissues granulate and cicatrize by means of a slightly stimulating

506

Progress of the Medical Sciences.

[Oct.

lotion of chlorate of potash. Velpeau has a high opinion of the sulphuric acid,
but could not succeed in making a paste with it to limit its action. This new
combination of manganic acid and potassa will, I hope, attract his attention,
and supply him, as well as my own countrymen, with an efficacious caustic,
convenient for application, less painful than all others, and free from injurious
effects upon the constitution. The well-known antiseptic effects of manganic
acid suggests its use in all foul and phagedenic ulcers, and I have no doubt
that large crops of warts may be conveniently removed by its agency."

17. Corrosive Sublimate and Collodion as an Escliarotic. — Dr. Macke states
(Medicinische Cent. Zeitung), that he has used with advantage an escharotic
composed of one ounce of collodion to one drachm of corrosive sublimate. He
has used it principally in naevi, and small excrescences which patients wish to
get rid of without the use of the knife. It is applied with a camel's hair
pencil, dries rapidly, and cannot be rubbed off easily. Applications of cold
water may be made in cases where the inflammation runs high, without inter-
fering with the action of the caustic. The eschar is thin, and falls off after
three or mostly six days ; pain is very slight, and the author has not found
that any absorption of the bichloride takes place. — Brit. Med. Journal, Aug. 1,
1857.

MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL

MEDICINE.

18. Etiology of Diabetes. Diabetic Sugar not the same as the Sugar produced
in the Liver in Health. — Dr. G-. Owen Rees, in his valuable Croonian lectures,
recently delivered before the Royal College of Physicians, makes the following
interesting remarks on this subject: —

"According to M. Bernard, we have not now to determine how a substance,
foreign to the healthy constitution of the blood, becomes engendered in the
system, but merely to inquire into the causes producing, on the one hand, an
over-activity in the sugar-forming action of the liver, or, on the other, the
diminution of the destructive power apparently possessed by the blood in
health over that sugar when it has mingled with the circulating fluid.

Now, all this is clear enough were the sugar secreted by the liver, and that
produced by injuring the base of the fourth ventricle, identical with that exist-
ing in the urine of true diabetes. This, however, is not the case, and we are
not, therefore, so nearly about to unravel the difficulty as we might, at first, be
inclined to believe.

About two years ago, I took the opportunity of obtaining blood from the
hepatic veins of a dog, in order to determine the presence of sugar; for, like
many others, I was, at first, a little incredulous. By the assistance of my
friend, Mr. Hilton, this was effected without much difficulty.

On examining the blood obtained in this way, I found, it is true, that it
yielded me sugar ; but there was a peculiarity in the reaction of the tests,
which led me to suspect I was not dealing with the same sugar as that con-
tained in the urine of diabetes. It was quite impossible for me at the time to
undertake a chemical investigation of the subject, and I was not sufficiently
satisfied with my results to venture on publication. Some months ago, I men-
tioned my suspicions to my friend, Dr. Pavy, who has thrown much light on
this interesting subject, and he told me that the same doubt had occurred to
him some time since, and he immediately showed me from his note-books that
he had worked the question out very satisfactorily, though he had not published
on the point. Having Dr. Pavy's permission to do so, I will now detail the
results of his investigations. It appears that the principal point of difference
between these sugars consists in the greater facility possessed by the hepatic
sugar, and by the sugar of artificial diabetes, of undergoing destruction by
contact with animal tissue. This has been shown by an experiment made on

1857.]

Medical Pathology and Therapeutics.

507

the sugar of artificial diabetes, comparing the result with that obtained by
similarly treating grape sugar and true diabetic sugar. The experiments were
conducted as follows: Three vessels were taken. In the first, a quantity of
pounded liver, obtained from a healthy dog, was placed with a solution of the
urine of artificial diabetes ; the specific gravity of the solution was 1045. In
the second vessel was placed pounded liver with a solution of common grape
sugar, of specific gravity 1040. In the third was placed pounded liver with a
solution of extract of true diabetic urine, of specific gravity 1040. The pounded
liver was used (as any other animal matter might have been) merely to induce
changes in the elements of these saccharine principles by its presence. The
three mixtures were now set aside for nine days. At the end of that time, on
submitting them to examination by Barreswil's solution, it was found that the
artificial diabetic sugar had entirely disappeared, while the reactions were ob-
tained in all their completeness from the two other solutions. Experiments
made with the same solutions, substituting blood for pounded liver, led to the
same results, showing a power of resisting decomposition on the part of grape
sugar and true diabetic sugar far exceeding that existing in sugar obtained by
the production of diabetes artificially.

There seems little doubt that the sugar of diabetes is a higher quality of the
principle, and that it can preserve its atomic arrangement with far greater
force than the- hepatic variety. A power, however, seems to reside in the
blood, which, after some length of time, eventually destroys, not only hepatic
sugar and that of diabetes artificially produced, but even that of true diabetes
mellitus. Thus, Dr. Pavy's experiments show that if the blood taken from a
diabetic be allowed to coagulate, and the serum then be separated from the
crassamentum, we can detect scarcely any evidence from the latter after a very
long exposure. In the serum, however, it can be detected in quantity till de-
composition is thoroughly set in. For some considerable time, both crassa-
mentum and serum give full evidence, however, which contrasts strongly with
the reaction of blood taken fresh from the right ventricle in health, and which
contains hepatic sugar, for here the sugar disappears almost immediately the
separation into serum and clot is completed. It is almost certain that when
we produce the artificial diabetic state by operation, we obtain in the urine the
hepatic sugar of the liver. It is also proved that this sugar of artificial dia-
betes is not the same as the sugar of true diabetes.

Now, of course, were these sugars identical, we might consider true sac-
charine diabetes as a disease in which the sugar-forming property of the liver
became abnormally active ; or, on the other hand, a disease in which normal
sugar was formed in the liver in usual quantity, but that the blood had lost
the power of destroying it when so formed, and that it, therefore, appeared in
the urine.

The results I have detailed place us, however, in a very different position.
We know now that true diabetic sugar is destructible only with great difficulty,
and that it is not the same as ordinary hepatic sugar. The question will then
arise — Are we to regard the sugar of diabetic urine as a modification of that
poured into the blood by the hepatic veins in health, or, on the other hand, as
a product of disease bearing no relation whatever to the sugar of the liver?

To those who have studied the subject of sugar in its chemical relations,
who are acquainted with its varieties and the facility with which these are
convertible into each other by the most simple processes, there will be no dif-
ficulty in believing that the sugar of diabetes may be easily derived from that
produced in the liver in health. Late experimenters on the sugars obtained
from the vegetable kingdom have shown how easily transmutations are thus
effected, and chemical properties developed or abstracted by simple contact
with materials apparently possessing anything but chemical activity. No one
can fail to be struck, for instance, with the curious fact that the sugar con-
tained in fruits possesses a certain action on light, influencing polarization,
which action is precisely reversed in the sugar obtained by crystallization from
the very same source. Thus, the gummy kind of sugar obtained from grapes
possesses the property of left-handed circular polarization ; but if we allow this
sugar to lie exposed, a kind of imperfect crystallization occurs throughout the

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Progress of the Medical Sciences.

[Oct.

mass ; and if we collect the granular crystals so formed, we find we have in
these a sugar differing materially from that originally extracted from the fruit.
Its chemical constitution is not the same. Its constitution is C12 H,4 014, in-
stead of C,2 II12 012 ; and when examined optically, it is found to possess the
property of right-handed circular polarization. The change appears to be
effected here by some constituent of the vegetable juice exercising its influence
as crystallization goes on — probably the acids play an important part. Now,
the liver, owing to some diseased action, may be supposed, in diabetes, to pro-
duce a sugar differing from that of health — a sugar which cannot be destroyed
by the changes taking place naturally in the blood — changes rapidly affecting
and destroying healthy hepatic sugar.

The phenomena of diabetes mellitus are, then, not quite so simple as the
experiments and discoveries of Bernard would, at a first view, make them
appear; and we have yet to determine the causes in action for the formation
of this abnormal sugar. Does the presence of a different ferment interfere —
even as we observe catalysis productive of varying results out of the body —
may not an analogous action be going on in the liver? and, if so, what may
be the nature of the ferment productive of disease, and whence is it derived?
Are we to look to the portal blood for the ferment, or controlling influence
which forms this less destructible sugar ? And is it owing to this diseased
state of blood that the liver, even though unaffected, is unable to cause the
changes occurring in health?

But we need not have recourse to the theory of a ferment. The portal blood
may present such principles to the liver as are only convertible into the true
diabetic sugar. So far as we can yet determine, then, the whole phenomena
of diabetic disease may eventually be traced to an abnormal state of the bile,
gastric-juice, and pancreatic secretion, any one or all of which may interfere
with the formation of healthy products in the portal blood, and so overpower
a healthy liver in the discharge of its office. Analogy would certainly, how-
ever, rather direct us to conclude that in diabetes the function of the liver
becomes altered under the influence of some cause as yet unknown. Bernard
has proved that the organ in health has a very strong transformative action on
grape sugar; and so powerful is this, that we should almost be entitled to con-
clude, even in the event of the portal blood bringing diabetic sugar, ready pre-
pared, into the hepatic circulation, that it would be metamorphosed by the
liver into normal hepatic sugar before it could reach the cava through the
hepatic veins.

These results, then, taken together, render it probable that we are to look
for the cause of diabetes mellitus in a disturbed state of the hepatic function,
not in an increase of natural action, but in an action varying in kind. We see
that in health the liver would reduce proximate animal principles to a normal
hepatic sugar, and, in the perversion of force occurring in diabetes mellitus,
we have a product given us approaching in character, it is true, to the normal
sugar, but by no means identical with it. There is great facility for theorizing
with respect to the agencies in operation in affecting this change of action.
As vegetable juices contain principles which, by simple contact, can alter the
chemical and optical qualities of the sugar first generated in the fruit, how
easy to believe that the elaborate fluids contained in the several parts of the
circulatory system of the liver may do the same. We know that acids are
active in the vegetable kingdom — we know that the liver substance is acid-
may not an over acid state cause the production of this abnormal sugar? or
may not even a too slow circulation through the organ (by allowing too long
contact with acid matter) bring about disease? These are questions requiring
much consideration." — Lancet, May 30, 1857.

19. Diabetes; Concretion on Kervus Vagus. By Hr. Ntman. — Early in the
morning of the 24th of August, I was requested by Dr. Zanteson to accompany
him to a Notary D., who had been taken suddenly and violently ill. On our ar-
rival we found the patient in a semi-comatose condition, with a small, weak,
and rapid pulse, cold extremities, and stertorous respiration. He was unable to
give an account of himself, and in answer to questions uttered merely some

1857.]

Medical Pathology and Therapeutics.

509

unconnected words. Dr. Zanteson now explained that the patient had long
suffered from diabetes mellitus, for which he had last spring been under treat-
ment, at the Seraphim Hospital, and had afterwards, during the summer, taken
the waters at Carlsbad, whence he had lately returned home. From a person
living in the next room to Notary D., we learned that after his return from
Carlsbad, he had lived rather freely, and had, for the last two days, complained
of feeling rather indisposed, but that he had, nevertheless, constantly attended
to his business, and was sprightly and cheerful. On the afternoon of the 23d,
he, for the first time, complained of headache and oppression of the chest, and
of shiverings alternating with febrile heat. However, no one had been with
him during the night, and in the morning the chamber-maid first found him in
the state above described.

At a time when cholera was prevalent, it was natural to suspect that this
sudden and violent attack was one of that disease. A glance at the patient
was, however, sufficient to dissipate such an idea. The face was bloated and
red ; the patient had had neither vomiting nor diarrhoea; on the contrary, he
had for several days suffered from constipation; the urine was voided in con-
siderable quantity; there was neither cramp, hoarseness, nor any other symp-
tom indicative of cholera. We now made an accurate physical examination,
but could discover nothing abnormal in either the thoracic or the abdominal
cavity; still all the symptoms indicated a speedy and fatal termination of the
case. Death occurred in the afternoon of the same day. Dr. Zanteson now
informed Professor Huss, under whose care the deceased had been in the hos-
pital, of his death, who requested us, at the "post-mortem, accurately to examine
the nervi vagi, in reference to the diabetes, under which the patient had
laboured.

The autopsy took place on the following day, the 25th of August, Doctors
Sydow, Granberg, and Lundberg, also being present.

The state of the principal internal organs was as follows : The membranes
of the brain were highly congested with blood ; there was no effusion either
under the arachnoid or in the ventricles. In the summit of each lung were
some few scattered crude tubercles ; there were no miliary granulations. The
heart, relaxed and flaccid, contained a little coagulated blood in the right ven-
tricle. The pleura and the pericardium were slightly adherent. The blood in
the larger thoracic vessels was dark and thick. The stomach, which was con-
siderably dilated, contained some spoonfuls of dark fluid, in which half-digested
white bonum magnum plums were floating. In the small intestines was no
trace of fluid; the mucous membrane was covered with a little yellowish brown
mucus. The transverse and descending colon were filled with masses of solid
excrement. The kidneys were hypertrophied and congested with blood. The
ureters were dilated. The bladder considerably enlarged, contained more than
a pound of urine. The liver was of natural size; its substance was flaccid
and loaded with blood.

After we had examined the above-named organs, we commenced the dissec-
tion of the nervi vagi. On the left nothing abnormal could be found, but, on
examining the right, we met, in the thorax, immediately behind the bifurcation
of the bronchi, a calcareous mass of the size of a hazel-nut, which was under
the entire trunk of the nerve, and appeared to have exercised considerable
pressure upon it.

This morbid condition now observed by us for the third time, in persons dead
of diabetes, gives additional support derived from pathology to the truth of the
ingenious Bernard's well-known physiological doctrine. It may, indeed, be
objected that the nervus vagus has other functions than the formation of sugar
in the liver to perform, and that these functions also ought to be disturbed by
a mechanical pressure on the vagus. But is not this, perhaps, in some mea-
sure the case in diabetes mellitus ? The voracity at least accompanying this
disease, seems also to depend on irritation of the vagus, which presides over
the secretion of the gastric juice.

Before closing this statement, I may be permitted to suggest a theory of the
origin of these calcareous concretions on the vagus. The calcareous concre-
tions we met in this case, bore at first sight a striking resemblance to a bron-

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Progress of the Medical Sciences.

[Oct.

chial gland, and such it was found on close investigation really to be. Was,
then, this ossified bronchial gland anything else than a blighted tubercle? At
least we may thus easily and naturally explain, not only the formation of such
calcareous masses on the vagus, but also the near connection, so long observed,
between tuberculosis and diabetes.

Hr. Huss mentioned that the person in question was under treatment in the
hospital for four or five months, in the latter part of last 3Tear, and the begin-
ning of the present. The urine then contained six or seven per cent, of sugar.
The appetite was inordinately great. The quantity of urine often amounted
to about three quarts (5 a 6 kannor) in the twenty-four hours. The urine
contained no uric acid. Both ordinary and extraordinary means were em-
ployed; among others, yeast. Astringents with opium somewhat diminished
the quantity of urine. By the advice of Hr. Huss the man went in the begin-
ning of summer to Carlsbad, although the prospects of improvement were not
great, the uric acid being absent. On his return from Carlsbad, he visited Hr.
Huss, and looked tolerably well, but in other respects circumstances were un-
changed. It is universally admitted that there are several forms of diabetes
which cannot be distinguished until after death. The present case, so strongly
confirmatory of Bernard's views, is an interesting example of one of these
forms. With respect to the nature of the concretion, Hr. Huss fully concurred
in Hr. Nyman's opinion. It is, however, remarkable, that only the formation
of sugar should be disturbed by such pressure on the vagus, and that other
functions dependent on that nerve, as those of respiration and digestion, should
not be in any way interfered with. The insatiable appetite in this case ought
also certainly to be regarded as a consequence of the affection of the vagi.

To a question by Hr. Carlson, whether uric acid was also absent in the two
cases previously communicated to the society, in which, on post-mortem exami-
nation, concretions were found on the vagus, Hr. Huss replied that he was not
able to give any positive information on the subject. — Dublin Hospital Gaz.,
July 15, 1857, from Transactions of the Swedish Society of Physicians.

20. On the Mortality from Eruptive Fevers at Different Periods of the Year. —
Dr. Tripe read a paper (June 1) before the Epidemiological Society, the main
results of which were as follows: 1. That smallpox presents two periods of de-
pressed, and two of elevated mortality ; the first period of elevation occurring
in January, and the second at the end of May, or early in June; the former
being the highest; the first period of depression being at the end of March or
early in April, and the second in September, the latter being the lowest; and
that, therefore, smallpox is most fatal in winter, next in summer, and least
fatal in spring. 2. That a series of cold springs is attended with compara-
tively a large mortality, and that the period of highest mortality coincided with
a temperature of less than 60° Fah., and the lowest of above 46° Fah. 3. That
the highest average mortality in the seventeen corresponding weeks of 1840-
56 was more than double the average lowest mortality. 4. That measles has
only one period of highest and one of lowest mortality, the former occurring in
December, and the latter varying in different years; but the rate of death in
spring is much smaller than in any other quarter. 5. That the rate of death
was greater in the series of spring and winter quarters which were below the
average temperature, than in those which were above it. 6. That, as in small-
pox, the average highest mortality during seventeen corresponding weeks in
1840 — 56, was more than double the average lowest mortality. 7. That scarlet
fever presents one period of highest and one of lowest rate of death, and this
more markedly than either smallpox or measles; the greatest number of deaths
occurring at the end of October or beginning of November, the lowest at the
middle or end of March, or early in April. 8. That the average mortality is
higher in warm springs than in cold. 9. That the mean of the greatest num-
ber of deaths in seventeen corresponding weeks of 1840 — 56 was about twice
and four-fifths as large as the mean of the lowest number of deaths in the se-
venteen corresponding weeks. 10. That there is not any particular short
period at which it can be said to reach its culminating point. 11. That the
greatest rate of death occurs in autumn, and the smallest in spring, the differ-

1857.]

Medical Pathology and Therapeutics.

511

ence between them being less than in any other eruptive fever. 12. That the
average maximum number of deaths in seventeen corresponding weeks in the
years 1840 — 56, was not much more than one-half that of the minimum. 13.
That the period of greatest mortality from diarrhoea is very definitely marked,
occupying a period of about seven weeks (from the 31st to the 37th), during
which more than two-thirds of the annual mortality takes place; the greatest
rate of death extending from the last week of July to the first week in Sep-
tember. 14. That this period corresponds with a mean weekly temperature of
60.5, or above.

21. Illustrations of Aguish Disorder prevailing in London during the last two
or three Years. — Dr. C. Handfield Jones, in a communication recently presented
to the Royal Med. and Chirurg. Soc, stated that, while he entertained a doubt
whether the cases selected presented any very striking points, he believed that
the series were not without value as illustrating a frequent character of dis-
ease; and he hoped that their consideration might shed some light on various
morbid phenomena of common occurrence, yet but imperfectly understood,
and often misinterpreted, and so might render their treatment more rational
and satisfactory. He wished the cases to be regarded as experiments in which
the nature of the morbid action was, to some extent, inferred from the mode
in which it was affected by remedial agents. He did not consider the evidence
demonstrative ;' he only claimed for it that the inferences should be regarded
as highly probable. Information of this kind, though very imperfect, may,
after all, be of far more use than the most exact determinations of the balance
and the microscope.

He premised the following statements : —

1. That local heat, congestion, and sometimes inflammation, may be produced
by paralysis of the vaso-motor (sympathetic) nerves of a part.

2. That the phenomena of fever can be well accounted for on the view of
paralysis of the sympathetic system. <

3. That there is good reason to believe that neuralgia and dysentery may be
the exponents of malarious influence as much as a true ague or remittent.

4. That there is much cause for believing that the vicinity of canals is un-
healthy, and that they generate a poison producing effects like those of malaria.

5. That the evidence respecting the production of malaria is such as makes
it impossible to affirm that it may not be generated by any moist surface in the
process of drying.

6. That, in cases of obscure and refractory character, the reaction of the
system towards remedies, and the effect of change of air, may afford most
material aid towards forming a correct idea of the cause and nature of the
disease.

7. The term malarious disorder, as used by the author, is not intended to
assert that the essential cause is always identical with marsh miasma; but
to convey the idea of a disorder, which, however produced, is exceedingly
similar to intermittent and remittent fever in many respects, maintaining the
same pathological affinities, operating on the same (nervous system), and re-
quiring the same treatment.

8. The primary action of fever poison, most notably of malarious fever, in
paralyzing and depressing affections, especially the nervous system. The most
deadly fevers are the algide, in which reaction never occurs; the phenomena
usually called febrile are, if the excitement be not over great, a desirable indi-
cation that the system rallies, and resists the morbid influence. Hence, if,
when there is no intense malaria, a patient suffer from continual, exceeding,
causeless (apparently), depression and debility, occasional chills and flushes
or perspirations, with an interlude of neuralgia at times, or a dysenteric or
rheumatic attack, and if benefited materially by quinine, iron, &c, and, most
of all, by change to a healthy locality, the inference that he laboured under
some aguish disorder seems legitimate. The system is habituated to the mor-
bid action, and does not react strongly against it.

9. The tendency to relapse is most difficult to eradicate. Any cause of a

512

Progress of the Medical Sciences.

[Oct.

debilitating kind will almost surely reproduce the morbid action in some form
or other.

He then gave the details of the following twenty-one cases: —

1. Obscure aguish disorder.

2. Rheumatic nasal inflammation.

3. Cerebral attack ; epistaxis. Benefit from quinine.

4. Cerebral attack ; failure of cerebral power. Benefit from ferrocitrate of
quinine.

5. Vomiting, febricitation, head-pain, exposure to ague poison. Cure by
quinine and strychnia.

6. Cerebral attack ; canal influence.

7. Scrofulous, epileptoid seizures. Cure by ferrocitrate of quinine and nux
vomica.

8. Hemiplegia in a neuralgic subject. General tonic treatment — recovery.

9. Hemiplegia, first of right, afterwards of left side ; canal influence.

10. Rheumatism of the oesophagus ; canal influence.

11. Rheumatism, thoracic neuralgia; depression; canal influence.

12. Cardiac neuralgia paralytica; slight hsematemesis. Cure by quinine
and iron.

13. Rheumatoid intrathoracic neuralgia.

14. Severe cardiac neuralgia; aguish attacks.

15. Periodic gastralgia. Cure by quinine and iron.

16. Rheumatic abdominal neuralgia.

17. Febrile affection; lingual neuralgia; cure by quinine and iron.

18. Dysentery and aguish disorder; cure by quinine and opium'.

19. Dysentery, rheumatism ; Crimean origin.

20. Nervous prostration, hemorrhage from stomach ; benefit from change of
air, cinchonine, and strychnine.

21. Fugitive oedema recurring frequently in various parts; cure by sustained
tonic treatment.

The author then proceeded to cite ten instances in which more decided ague
was originated or developed by a residence in London. In conclusion, he drew
the following deductions:—

1. There seems much reason to think that an obscure form of aguish dis-
order prevails in (at least) the western parts of London, the phenomena being
chiefly great debility, hyperesthesia, failure of cerebral power, neuralgia of
external or internal parts, gastric disorders, rheumatic affections, and ill-deve-
loped febrile paroxysms; quasi-apoplectic seizures are not uncommon.

2. Quinine, iron, and strychnine, are found of decided benefit, with a gene-
rous diet.

3. Change to a pure air is the best remedy. ■

It must be apparent that, if there be any truth in the foregoing views, those
who ignore them entirely must practise at great disadvantage, and meet with
continual disappointment. The opinions advanced in the paper are mainly
derived from Dr. Macculloch's writings, whose opinions are strongly corrobo-
rated by Dr. Copland.

Dr. Webster believed that ague was now far less common in London than
formerly. The disease was a very common one two or three hundred years
ago, James I. and Cromwell having died from it. When the population of
London was not one-fourth its present amount, the deaths from ague were
more numerous than now. The average number of deaths in London from
real ague did not exceed twenty-four or twenty-five per annum. The disease
was more common in the western parts of London than in the other districts,
a circumstance which he attributed to the excavation of a considerable quan-
tity of virgin soil on which the new houses were erected, and to comparatively
inefficient drainage. IP, agreed with the author in thinking that residence
near canals was productive of aguish disorders, and instanced a case in which
out of 1400 inhabitants in a village on the Rhine, in the neighbourhood of a
new canal, more than 1100 suffered severely from those maladies, accompanied
in many instances by dysentery. The disorders were more common in men
than in women, and in middle than in early life, though the most severe case

1857.]

Medical Pathology and Therapeutics.

513

he had seen was that of a child, six weeks old, in the hospital at Tours, a dis-
trict surrounded by canals and rivers. Quinine was doubtless the best remedy ;
but he had seen some exceptional cases in which that medicine had had no
effect, and which had been successfully treated by purging. He should not be
disposed to give quinine with strychnine, thinking that the one would counter-
act the effect of the other. — Med. Times and Gaz., July 18, 1857.

22. On Spancemia, Chlorosis, and Analogous Conditions, as the Predominant
Characteristic of the Present Age. — Dr. Pollitzer takes a very gloomy view of
the condition of the human race at the present time, and considers it to be an
established fact that the physical deterioration in Europe is profound, " a sad
memorial of civilization." He admits the general diminution of mortality in
all eivilized countries, but affirms this to be a fallacious test, as there is not a
corresponding increase in the health and vigour of the race, or in the number
and character of the diseases. The reduction of the mortality, the author at-
tributes to the increase of hospitals and similar charitable institutions — to
quarantine, vaccination, and numerous sanitary regulations. The boundaries
of health and disease, he observes, are daily becoming less marked, and he
considers it characteristic of modern pathology to affirm that there are numer-
ous conditions which are undoubted deviations from the healthy standard,
though it is impossible to delineate or give definite portraits of them, because
they make their appearance during a state of " relative health." The physician
has no name for the disease, but the patient maintains that, not feeling in health,
he has no alternative but to call himself ill. This anomalous condition, Br.
Pollitzer accounts for by the spansemia and chlorosis, which he regards as the
feature peculiar to our times — the soil in which the feebleness and deteriora-
tion of our race take root. After developing his views more in detail, the
author proceeds to show how these conditions are fostered by modern civiliza-
tion. A constant stretch of the mental powers — a restless excitement of the
passions — a perpetual struggle for advancement — the fresh wants of every day,
science and the arts themselves being subservient even to the luxury and de-
moralization of the times — the destruction of all moral harmony and peace —
are advanced by Dr. Pollitzer as the evils of modern civilization. And these
evils react especially upon the younger generation ; and the demands made
upon the youth of eighteen or twenty of the present, would formerly have been
considered a sufficient tax for the strength of a man of upwards of five and
twenty. He inveighs especially against the polymathy (if we may coin the
word) of children, among whom the spansemia and chlorosis of the age espe-
cially flourish.

Having for seventeen years devoted himself to the study of children's dis-
eases, he has arrived at the conclusion that the features which characterize our
age have their source in the treatment of childhood, and that the deterioration
of the race at large takes its origin in that of childhood.

The facts upon which Dr. Pollitzer bases his remarks are, that anaemia and
chlorosis occur alone, or associated with rickets, hypertrophy of the lymphatic
glands, and of the spleen and liver, to an incredible extent, even from the first
month of life. Of 1,000 children that were treated in the children's hospital,
on an average, 700 — 800, or from 70 — 80 per cent., were thus affected. He also
observed that the anomalies of the blood and constitution, which are so widely
diffused, invariably appear where the nutrition of the child has been imperfectly
effected. The stomach and intestinal tract are the parts that first suffer ; hence
it is in these organs that we discover the prevailing morbid conditions of child-
hood ; and while they materially influence the mortality of children, they equally
affect the state of their future health when they survive childhood. — British and
Foreign Medico- Chirurgical Review, July, 1857, from Zeitsc. des K. K. Gesellsch.
der Aertze, February, 1857.

23. Redness of the Cheeks as a Symptom of Pneumonia. — Dr. A. Gubler takes
up the old doctrine that the redness of a cheek in a case of pneumonia, indi-
cates the side on which the disease lies. Modern authors have paid little at-
tention to the subject, but Dr. Gubler has satisfied himself, by extensive obser-
No. LXVIIL— Oct. 1857. 34

514

Progress of the Medical Sciences.

[Oct.

vation in the Salpetrieres, that the general law is true. The author has guarded
against the fallacy which might result from the patient lying on the cheek pre-
senting the greater redness, and has measured the relative temperature of the
two sides of the face with the thermometer. Numerous cases are detailed, and
the following is the summary of his observations : 1. The redness of the cheeks,
which commonly coincides with pulmonary inflammation, is not, as is commonly
thought, a fortuitous circumstance, but a functional disturbance bearing a de-
finite relation to the disturbance of the respiratory passages. 2. This redness
is not necessarily proportioned to the extent and degree of the anatomical lesion,
but bears a relation to the intensity and progress of the inflammatory action.
3. A sensible, and sometimes considerable elevation of temperature (from 0.50°
to 5.40° Cent., or nearly 1° to 10° F.) accompanies the hyperemia, and gives it
the character of active congestion. 4. The congested cheek corresponds to the
lung which is the seat of phlegmasia, or the one which is most affected. 5.
The flushed cheek is seen, not only in pneumonia, but also in the majority of
other pulmonary inflammations — in those which accompany tuberculization, as
in typhoid pneumonia, and even in capillary bronchitis. It appears to be most
marked in pneumonia of the apices — a circumstance already pointed out by
Bouillaud. 6. The production of other morbid conditions may be promoted
by the habitual hyperemia of the face ; thus a spot of erysipelas has been seen
developed on the cheek of the affected side. 7. The redness of the cheeks in
acute diseases of the lung may be explained by the stimulation of their nervous
plexuses extending to the brain, and reflected upon the respiratory nerves of
the face. 8. The phenomenon may be regarded as a manifest example of sym-
pathy established between two distant regions by the agency of the nervous
system. — British and Foreign Medico- Chirurgical Review, July, 1857, from
L' Union Medicate, April and May, 1857.

24. New Premonitory Symptom of Cholera. — Dr. Poznanski, in a communi-
cation to the Imperial Academy of Sciences, states :—

1. That during the prevalence of cholera it frequently happens that the pulse
is extremely low, and reduced to 45 or even 42 in persons apparently in per-
fect health. 2. That this symptom is unaccompanied by any other denoting a
morbid state. 3. That when the pulse is low, the blood becomes dark and
viscous ; while in persons whose pulse is in a normal state during the epidemic,
the pulse is perfectly healthy. 4. The cholera only attacks those that have
previously experienced a diminution in their pulse. 5. That this diminution,
which often occurs weeks before the regular attack, may be considered a path-
ognomonic symptom of the approach of cholera. 6. That those who have ex-
perienced the diminution in question have always escaped the disease whenever
they have followed a regimen calculated to accelerate the circulation. 7. That
the falling off of the pulse, and therefore the predisposition to the disease, are
in general proportional to the want of energy in the circulation of the blood
and to the excess of atmospheric pressure. 8. That this diminution does not
occur in healthy subjects when the epidemic has ceased. — British Med. Journ.,
Aug. 1, 1857.

25. On the Application of the Microscope to the Diagnosis of Pulmonary
Consumption. — Dr. Theophilus Thompson recently read before the Harveian
Society, an interesting paper on this subject. We observed that the assiduous
and discriminating use of the microscope having yielded valuable aid in illus-
trating various pathological questions, and giving precision to some grounds
of diagnosis, it seemed reasonable to anticipate information from the appli-
cation of this instrument to the examination of expectoration ; and he thought
it practicable to show that the disappointments which some observers had
experienced in their endeavours to avail themselves of this method of in-
vestigation did not depend on inadequacy of the means, but might be overcome
by care and perseverance. Many years since, Mr. Quekett detected elastic
pulmonary tissue in the sputum of patients not previously considered con-

1 Nosographie M^dicale, torn. xi. p. 484.

1857.]

Medical Pathology and Therapeutics.

515

sumptive, and it was for a time supposed that a peculiar granular appearance
of the expectoration might be regarded as characteristic of tubercular disease,
even in the absence of any trace of elastic tissue. Finding, after a time, that
this appearance could not be relied on as an indication of incipient phthisis,
and embarrassed by the multiplicity of objects often present in the expectora-
tion, Dr. Thompson for a time discontinued the investigation, any sanguine
expectations which he had entertained being further discountenanced by the
testimony of Rainey, Addison, and Bennett;1 but in an interview with Dr.
Andrew Clark (to whose sagacious observation and faithful descriptions2 the
profession is greatly indebted), he had the gratification of learning that the
subject had engaged his attention since the year 1846, and with such success
as to enable him to show, in his lectures at Haslar, the real microscopical
indications of tubercular sputum. With his friend's liberal and courteous
assistance, Dr. Thompson soon became convinced that changes in the pul-
monary vesicles, preceding the stage of destruction which occasions the elimi-
nation of pulmonary tissue, are manifested in the expectoration, and that
information may thus be obtained, not only supplying valuable aid in diag-
nosis, but also furnishing instructive information regarding the morbid
process concerned. Dr. Thompson showed, by a diagram enlarged from a
drawing by Shrceder Van der Kolk, that when tubercular deposit is present in
the pulmonary vesicles, there may be seen, contrasting with the usual epithelial
cells, some which are dark, swollen, spherical ; some more advanced, larger,
and misshaped; others shrivelled or burst, and extruding nuclei, which
nuclei, when enlarged, correspond with the " tubercle corpuscles" of Lebert.
The author proceeded to show that the sputum of consumptive patients contains
materials corresponding in appearance with the elements present in the air-
vessels, and that before an amount of disease involving the elimination of
elastic areolie occurs, corpuscles of various sizes, jagged outline, setting free
nuclei, and affording evidence of rapid disintegration, may be detected. The
general moleculo-granular appearance (to which his attention had been
originally directed, and which he much regretted having erroneously figured in
his "Clinical Lectures") was not conclusive; the sputum which is really
characteristic containing isolated masses of moleculo-granular material, and
having interspersed corpuscles of various forms, overgrown or jagged, and
setting free nuciei ; the various proportions of pus, or fat, or blood, giving
collateral indications of the amount of surrounding deterioration in the lungs ;
while amongst evidences of rapid progress might be specified the appearance
of large and numerous areolar meshes, still retaining their adhesion and elas-
ticity. In chronic cases, portions of this tissue appear, inelastic, teased out, and
broken down, in consequence of long imprisonment, whilst a diminished pro-
portion of fat, and the appearance of cholesterine plates, and still more of earthy
particles, were often indicative of a mode of restoration. The author proceeded
to prove, by a brief narration of cases —

First, that with the aid of the microscope positive conclusions, not attainable
by auscultation, could sometimes be formed regarding the existence of pul-
monary disease.

Case I. — Mr. , aged sixty-three, after an attack of pleurisy in the left

side, during the spring of 1855, did not regain strength. Dull percussion, and
prolonged expiratory murmur over a small portion of the right apex were the
only important auscultatory signs; but the expectoration, under the micro-
scope, was found to contain blood corpuscles, moleculo-granular matter, and
lung tissue broken down and unbent. More positive symptoms of decided
phthisis, as reported by his medical attendant in the country (Dr. Sylvester,
of Trowbridge), soon appeared, and in a few months he died.

Case II. — Mrs.E , a lady, aged thirty-nine, whom Dr. Thompson attended

with Mr. Marshall, of Bedford Square, during the early months of 1855 suffered

1 Dr. Hughes Bennett has lately added his testimony to the value of the microscope
in suspected phthisis. Vide Edinburgh Monthly Journal, Jan. 1856, p. 585.

2 Vide Transactions of the Pathological Society, vol. vi. p. 74 ; and Lettsomian
Lectures, by Theophilus Thompson, M. D., F. R. S.

516

Progress of the Medical Sciences.

[Oct.

from obstinate sickness, which was supposed to depend on gastric affection.
The persistency of the sickness and the progressive emaciation inducing an
examination of the chest, some dulness on percussion with increased vocal thrill
was observed near the sternal end of the second intercostal space on the right
side. A little expectoration was obtained, and was found to contain shrivelled
cells, lung tissue, and isolated masses of granules. Some improvement of the
general health occurred under soothing hygienic and tonic treatment, and the
administration of cocoblein. But early in the year 1856 the expectoration
became copious and flocculent ; dulness on percussion was more extensively
obvious ; near the inferior angle of the scapula click was audible, shortly fol-
lowed by cavernous breathing. In March she died. An interesting contrast
to this history was afforded by

Case III. — A lady, aged thirty-eight, who, in the autumn of 1852, had almost

precisely the same auscultatory symptoms as were observable in Mrs. E ;

but the occasional, slight, cloudy expectoration, from time to time examined,
exhibited ciliary cells, some with long tails, probably tracheal, some in masses,
as though from the follicles ; but there were no tubercular elements. In har-
mony with the encouraging testimony thus afforded by the microscope, the
general symptoms continue favourable, and have hitherto, during a period of
five years, negatived the gloomy prognostications which an accomplished aus-
cultator had perseveringly maintained.

Secondly: the author adduced the advantage of microscopical observation in
confirming doubtful signs.

Case IV. — E. T , aged fifty-one, in the winter of 1854 was attacked

with cough, hurried breathing, and some symptoms of hectic. The left lung had
been extensively consolidated in consequence of pleuro-pneumonia ten years
previously. Over a small space near the lower angle of the left scapula a
sound could be heard, of which it was difficult to determine whether the correct
designation were subcrepitation or click. Dr. Andrew Clark, who also oblig-
ingly examined the expectoration, reported that it contained shrivelled cells,
large cells with shrivelled nuclei, and some earthy matter, and, without receiv-
ing any history of the case, offered the diagnosis of " Slight tubercular deposit,
tending to restoration a diagnosis which was confirmed by the result.

Thirdly : Dr. Thompson described some favourable indications afforded by
the microscope concurrently with amelioration in the general condition.

Case V. — Mr. , aged twenty-two (introduced by Mr. Pinching of Graves-
end), five feet nine inches in height, in the summer of 1854 had dull percussion
and a murmur over the left pulmonary artery, but no crackle or click ; the
expectoration, however, exhibited lung tissue, tubercle corpuscles, and blood-
disks. He took cod-liver oil freely, at one period to the extent of a pint and a
half in a week ; and had ioduretted neat's-foot oil (a grain to the ounce)
rubbed into the chest. After a time the expectoration became chiefly bronchial,
disposed to fibrillate, and free from lung tissue. The weight of this patient
increased from ten stone one pound to eleven stone nine pounds. He spent
last winter in Madeira.

Fourthly: the author noticed the important evidence sometimes derivable
from the sputum, indicative of rapidity in the progress of disease.

Case VI. — A lady in the country, aged forty-three, who had been for two
years the subject of phthisis, but whose friends did not fully realize the danger,
had a decided aggravation of cough and weakness. Some expectoration, sent
to town for examination, contained blood, copious pus corpuscles, and nume-
rous large meshes of pulmonary tissue, perfectly retaining their form and
elasticity. A very unfavourable prognosis was consequently given, which was
verified by the death of the patient a few days afterwards.

The author, in conclusion, ventured to express the opinion that his state-
ments, although brief, were sufficient to support his proposition, that the
microscopical inspection of expectoration might often afford, at a very early
period of consumption, definite information, not otherwise attainable, regarding
the nature of the malady ; that in later stages of disease it might assist us to
estimate the rapidity and progress, and at all times might furnish valuable aid
in forming a correct prognosis regarding the course of the complaint. He

1857.]

Medico! Pathology and Therapeutics.

517

trusted these few suggestions would stimulate to the investigation some of his
professional brethren more accomplished in the use of the microscope, or more
fortunate in the enjoyment of leisure. — Lancet, July 11, 1857.

26. On Movable Kidneys. By Prof. Oppolzer, — The knowledge of the pos-
sibility of the existence of this affection is of importance to the practitioner,
as, when unaware of it, he may suppose the appearances observed to result
from various other causes, and submit the patient to an injurious course of
treatment, or give rise to unnecessary alarm upon his part. The abnormal
movability usually affects but one kidney, and especially the right one ; but
the author has met with cases in which it was observable in both, and that in
a remarkable degree. In all the cases he had the opportunity of examining,
the patients dying of some other disease, the kidneys were found healthy ; but
in these cases there has been observable a deficiency in the cushion of fat, and
an extension of the renal vessels. In some cases, the practitioner's attention
has been drawn to the abnormality by the patient observing a tumour on one
or both sides of the abdomen, which only became perceptible while standing,
or lying on one or the other side, disappearing again during the horizontal
posture. Generally speaking, however, it is first discovered by careful ex-
ploration, when, beneath the relaxed, painless, and not very obese abdominal
parietes, a largish, rounded tumour is perceived deep under the liver or stom-
ach. The inner concave side can only be felt in very thin persons, and the
upper end is only accessible in some. The tumour can easily be pushed. up-
wards, and then may suddenly disappear, but it cannot be pressed against the
spinal column, or downwards below the crista ilii, without great pain being
produced. To very firm pressure, made in any direction, the tumour is sen-
sible ; and the patient spontaneously complains of a sense of pressure and
dragging, especially when standing, performing active movements, during
defecation, etc. In the cases seen by the author, the condition of the urine
has been normal.

The affection is usually congenital, as is shown by the lengthened condition
of the vessels. Rapid emaciation occurring in persons formerly fat, concus-
sion of the body, as in rough travelling, constipation, etc., may probably con-
tribute to its production. In fat persons, the diagnosis may be impossible,
but it is not difhcult in those who are thin, as the form of the swelling can be
traced, while the tumour can be pushed into the lumbar region, and there felt.
The pain which it not unfrequently gives rise to cannot be mistaken for neu-
ralgia, colic, or rheumatism, if the practitioner will only make an exact ex-
ploration ; while the tumour resulting from a collection of feces assumes
another form, and does not appear in, or disappear from the lumbar region in
consequence of pressure. It may also be distinguished from a movable
spleen, as the latter lies in front of the intestines under the parietes, and gives
rise to dulness on percussion, which the kidney does not. It can only be con-
founded with cancerous and tubercular masses, when these are movable, and
resemble the kidney in form. Treatment of this affection by bandages, and
the like, is of no avail ; and the removal of pain when present must chiefly be
sought from the horizontal posture. Confinement of the bowels, and the con-
sequent straining, must be avoided. It is, however, of great importance to be
able to tranquillize the mind of the patient as to the nature of the affection,
and to prevent injurious measures being adopted; and hence the value of a
correct diagnosis. — Med. Times and Gaz., June 6, 1857, from Wein Wochen-
schrift, No. xlii., 1856.

27. Open Foramen Ovale in the Adult. — Some years since (1851), Dr. J. W.
Ogle examined sixty-two human hearts, with a view of discovering the con-
dition of the foramen ovale, and found that of these there were thirteen in
which this foramen was incompletely closed, or one in five. The patency no-
ticed allowed of very different degrees of communication, between the two sides
of the heart. " In some of the cases, the opening remaining in the septum of
the auricles was a mere fissure or oblique slit, arising simply from want of such
an adhesion between the valves and the margins of the isthmus as is wont to

518

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[Oet.

exist after the completion of the drawing up of the valvular fold and other
preliminary contractile actions of neighbouring parts. This defective adhe-
sion. I may remark, is thought by Dr. Peacock to be the result of unequal
pressure in the auricles from the blood, owing to the slow establishment of
the pulmonary circulation after birth. The oblique slits, to which I have
alluded, were directed variously, as it were, opening in some cases more widely
from above, and in others from below, and would have allowed of the blood
passing, as it would seem, more freely in some cases from the left into the
right auricle, but in the majority of cases from the right into the left auricle.
In several of these cases, the communicating opening was not merely that of a
chink or slit, but was a decided round or oval aperture; in one case admitting
of the entrance of the tip of the little finger. In one or two cases the opening
was of a reticular character, having the appearance as if it had been produced
by a falling short of one part of the margin of the valvular fold, so that it failed
to be raised to the level of the isthmus, to which it ought to have been adherent;
and as if the deficiency had been in part compensated for by bands passing
across the vacancy. I was careful in my search for any trace of ulceration or
of rupture which might have accounted for the opening, but this did not in any
case exist."

Dr. 0. has recently referred to the life histories of these cases, in order to
ascertain what physical signs were noticed before death, which might be attri-
buted to this imperfect closure : and he states that in these thirteen cases "there
are seven in whose histories it is emphatically stated or to be inferred that no
murmur synchronous with the systole of the ventricles, that is also synchronous
with the diastole of the auricles, existed; and only one in which there is notice
of any murmur with the diastole of the ventricles — that is, with the systole of
the auricles. Consequently, excepting in this last single instance, we have the
fact of six hearts in which more or less patency of the foramen ovale existed,
but did not give origin to any unnatural sound whatever about the heart. In
the solitary instance (Case 3) in which a regurgitant or diastolic murmur (so
called) was heard, the heart was very large and soft, and recent granulations
and shreds of fibrinous material, deposited from the blood, were adherent to
the aortic valve-flaps. It may therefore well be believed that this murmur was
seated in the left ventricle, and had nothing to do with the septum of the au-
ricles ; if it had any such connection, it must have been produced during the
systole of the auricles, and therefore not at all similar to that in Dr. Mark-
ham's case, which took place during the ventricular systole, and was supposed
by him to be produced during the diastole of the auricles. As regards the last
six cases, in which the closure of the foramen ovale was imperfect, I am sorry
to say that the life history does not afford data from which any conclusive evi-
dence as to the presence of cardiac bruits may be derived. It will be remem-
bered that in all these thirteen cases the patients were adults. In none of them
was there any cyanosis noticed during life, or congenital malformation of the
heart or its vessels found after death. Moreover, there was no such condition
of the valves or orifices of the heart as should primarily or secondarily tend in
any material degree to impede the blood's exit from the auricles, and thus, as
it were, throw greater pressure and stress upon the septum along with other
parts of their walls, and lead to a mixture of the venous and arterial blood
through the foramen ovale. There was, however, in many cases, marked and
extensive disease of the lungs, such as their occupation by the products of in-
flammation or scrofulous deposit, which, though to a less extent, would have a
similar tendency as regards the right auricle.

" I may be permitted here, as I have his sanction, to append a case lately
brought before the notice of the Pathological Society by Dr. Ogier Ward, which
I will curtail. It bears strongly upon the point I am attempting to illustrate.

" The case was that of a child who died eleven days after birth, having been
cyanotic and affected with dysphagia and choking on swallowing. The lungs
and heart were auscultated during life, and it was noticed that the heart's sounds
were natural, no bruit existing. After death, congenital communication be-
tween the trachea and oesophagus was found, with enlargement of the pulmo-
nary artery and patency of both the ductus arteriosus and foramen ovale. The

1857.]

Medical Pathology and Therapeutics.

519

preparation is now in the museum of the College of Surgeons. This case,
added to those related above, makes the seventh case in which the foramen
ovale was more or less patent during life, and in which we have evidence that
no bruit was thereby produced. "

In the number of the British Medical Journal for April 4, 1857, Mr. Markham
relates a case in which a loud murmur, coincident with the systole of the ven-
tricles, was heard along the base of the heart, and in the entire left subclavian
region.

" In this case," remarks Dr. Ogle, "nothing unnatural was found after death
in the condition of the heart beyond a patent state of the foramen ovale, allow-
ing the blood to pass readily from the right to the left auricle, but not permit-
ting it to pass in the opposite direction, excepting through two narrow slits.
Among other remarks in connection with it, Dr. Markham suggests the very
important query whether this peculiar state of the foramen was sufficient to
account for the very marked and widely extended systolic murmur heard during
life ; so marked, indeed, that before death it was described as loud, rough, and
prolonged, audible over the whole prcecordial region, and over the upper part
and along the right border of the sternum, and in the whole of the upper half
of the interscapular space. Dr. Markham supposes that in many cases of open
foramen ovale, under certain circumstances, this state induces murmur during
the systole of the heart. If this state of the foramen be accompanied by other
unnatural states of the heart producing any murmur, then the murmur caused
at the septum of the auricles becomes masked and hidden ; and if there be no
such disease in other parts of the heart, then no heart symptoms arise, and
thus the heart remains unexamined during life, and consequently the aforesaid
auricular murmur not detected. He says : 'Is it not possible that such a mur-
mur may have been present in many cases simply of open foramen ovale, but was
not discovered during life, because the disturbance to the circulation produced
by the same lesion was not of itself of a nature marked enough to excite atten-
tion V Again : ' Cases where the foramen ovale must have been partially open
during life, and yet where no symptoms to mark the fact had been observed,
are frequently met with ; and assuredly in the majority of these cases it would
be a complete begging the question to affirm that no murmur really existed
during life. It is more correct to say that in the very great majority of cases
of simple open foramen ovale disturbances in the circulation do not occur, and
therefore no examination of the heart is made during life. Practically speak-
ing, how many cases are there on record where simple foramen ovale has been
found after death, in which the observer can affirm that no murmur existed
during life? I suspect very few/ It is with this last question only of Dr.
Markham's that I am now concerned ; and though in what I have brought
forward I do not say that I have shown reason for supposing that a murmur
cannot, under any circumstances, be produced by the passage of blood through
an open foramen ovale, yet I have, as I think, shown that there are numbers
of cases, under ordinary circumstances, in which, although facility for the
passage of blood from one auricle to another exists, yet no unnatural sound is
thereby of necessity produced. This is so, judging from the cases adduced,
even when considerable obstruction to the blood's passage through the lungs
must in many cases have been present. It may be that with a certain degree
of patency, a certain tension of the boundaries of the foramen, a certain quality
of the blood as to consistence, and a determinate force with which the blood is
propelled by one or other auricle — under all these conditions it may be a mur-
mur might possibly be caused at an open foramen ovale. More extended obser-
vations than have hitherto been made on the matter are, however, yet required
to establish the fact." — British Medical Journal, June 13, 1857.

28. Combined Constitutional and Local Treatment of Hooping- Cough. — Dr. R.
Pearce states [Lancet, April 11. 1857) that in 75 cases of hooping-cough (32
boys and 43 girls), varying in age from 2 to 8 years, which came under his
charge during last autumn, in a school containing over a thousand children,
he used the local treatment recommended by Dr. Eben Watson, viz., sponging
the glottis once a day with a strong solution of nitrate of silver (one scruple

520

Progress of the Medical Sciences.

[Oct.

to one ounce of distilled water) by means of a curved probang ; and, in com-
bination with this, he ordered Dr. Gibb's nitric acid mixture (dilute nitric
acid, twelve drachms ; compound tincture of cardamoms, three drachms ;
water, one ounce ; simple syrup, three ounces and a half), a teaspoonful every
three hours. He also, from the commencement, gave a teaspoonful of cod-
liver oil twice a day, and, at the same time, kept the patients on generous diet
and in warm yet well-ventilated rooms. This treatment, he asserts, has in his
hands been invariably successful.

29. On Bloodletting in Pneumonia. By Prof. Wunderlich. — In the course
of five years, there have been treated at the Leipsic Klinik 204 cases of pneu-
monia, of which number 36 (17.06 per cent.) ended fatally ; but if we abstract
from these those cases which were brought to the hospital in extremis, and
count only those which were actually treated there, there were then 190 cases
with 11 deaths (11.57 per cent.). Among the fatal cases, 3 were treated by
bleeding, as were 44 of the cases that recovered, making the mortality of these
so treated 6.38 per cent. These fatal cases were examples of pneumonia com-
plicated with the disease of other organs.

In 114 of the patients, loss of blood occurred during the course of the pneu-
monia, whether from local or general bleeding, epistaxis or menstruation ; and
of this number 9 (including the 3 treated by bleeding) died, i. e., 7.89 per cent.
In 76 cases, no loss of blood whatever occurred during the progress of the
case, and of these 13, or 17.10 per cent, died, not including persons brought in
agony, and who had not in general been treated by bleeding. Thus it results
that — 1. In cases in which there was loss of blood in general the mortality was
7.89 per cent. 2. In those in which venesection had been employed 6.38 per
cent. 3. In those in which a complete conservation of blood took place a mor-
tality of 17.10 per cent.

The author enters into an elaborate comparative statement of the influence
which the loss of blood exerts upon the time and mode of termination of the
fever and of the commencement of the healing process. Pneumonia, he ob-
serves, possesses, in the vast majority of cases, the peculiarity of commencing
with very determinate symptoms (severe chills, unequal distribution of the
blood, and rapid increase of the objective temperature of the trunk), which
are immediately followed by acute continued fever (increase of temperature,
rapidity of pulse, etc.). In favourable cases, there is this further peculiarity,
that at about the period of the completion of the exudative process (cessation
of increased dulness on percussion, and of the bloody sputa) the febrile symp-
toms rapidly disappear, the delirium alone continuing awhile if it has been
very violent. In this respect, pneumonia approaches the eruptive fevers, and
forms a contrast to other inflammatory diseases, as abdominal typhus, pleurisy,
peritonitis, meningitis, bronchitis, etc. Wishing to avoid the ambiguity
which would ensue upon the adoption of the word crisis, the author designates
this passage of the economy from a feverish to a feverless state, defervescence.
It is no accidental occurrence, but a process which is sometimes rapid, some-
times slow, and may be complete or incomplete, protracted, uninterrupted, or
remittent. A rapid defervescence is decisive for the quick convalescence of the
patient ; but, while cases in which it is remittent are rare, yet, when it is pro-
tracted or interrupted, it is of bad augury for the patient, even when the dis-
ease is slight.

As a standard forjudging the effects of therapeutical agents upon the period
of defervescence, the Professor first selects 32 cases treated by expectation,
and in which the exact time of its commencement was noted. Taking 10 of
severe and 10 of the medium cases, the defervescence commenced at the
seventh or eighth day ; but, taking the entire number, in adding 12 slight
cases, it occurred at the sixth or seventh day. Judging from 9 cases which
came under his notice (2 of menstruation and 7 of epistaxis). spontaneous
bleeding proved rather favourable, as the improvement dated from the appear-
ance of the bleeding.

Local without general bleeding was followed by recovery in 36 cases. In 26
it was employed either alone or in conjunction with medicines, such as digi-

1857.]

Medical Patliology and Therapeutics.

521

talis or ipecacuanha, which exert no appreciable effect in expediting the period
of defervescence, and in 10 it was combined with tartar emetic, which does
exert an effect of this kind. Of the first series, rapid defervescence took place
in 7 slight and medium cases in from the third to the sixth day, and in 19 bad
cases it varied from the second to the ninth day. In the 10 cases of the second
series, it took place from the third to the seventh day.

In 39 cases in which the commencement of the disease could be accurately
ascertained, venesection was employed. First, in 18 of these it was employed
on the first or second, day. In 10 of these there was immediate arrest of the
process ; in 2, immediate arrest with a somewhat slower continuance of im-
provement; in 5, a considerable diminution of fever, with a later but less con-
siderable return, the fever ceasing in 4 cases on the sixth, and in 1 on the
seventh day. In 1, no effect was produced, improvement following only after
local bleeding. Secondly, in 21 the venesection was performed from the third
to the fifth day ; but in none of these cases was bleeding the only means em-
ployed. The results obtained even here contrasted very favourably with those
obtained by expectative treatment. It was found that the conjunction of tartar
emetic hastened the period of defervescence somewhat; that of local bleeding
was scarcely of any effect, while the addition of digitalis was of no effect what-
ever.— Med. Times and Gaz., June 6, 1857, from Virchow's Archiv., 1856.

30. Glycerine in Consumption. — There is much difference of opinion among
medical men as to the influence of glycerine upon cases of consumption, some
considering it scarcely inferior to cod-liver oil, while others regard it as value-
less. With a view of testing its power, Dr. R. P. Cotton administered it in
doses of one, two, and three drachms, twice a day, to twenty-three of the in-
patients of the Consumption Hospital, Brompton. In only five of these was
there any improvement, in all of which the weight was slightly increased. In
two of these, however, a much greater advantage was subsequently gained
under the use of cod-liver oil, the weight of one patient having increased as
much as two pounds per week.

In seventeen cases, either there was no appreciable improvement, or the
patients became worse ; and one, in an advanced stage of the disease, ended
fatally. In nine of these cases, more or less improvement occurred from the
after use of the oleum aselli ; in four instances, indeed the gain in weight was
very distinctly marked.

In five cases, the glycerine either caused sickness, or otherwise disagreed
with the stomach.

To any objection which may be raised that the glycerine was not given for a
sufficiently long period, I would merely observe that, even in the cases where
some improvement was noticeable, it appeared to me so probable that far
greater good would accrue from the cod-liver oil, that I regarded a further
trial of the other as unjustifiable ; and that such an anticipation was, in some
instances, at least, not ill founded, the table sufficiently demonstrates.

The following conclusions are, Dr. C. thinks, irresistible, viz. : —

1. That glycerine has generally but little influence upon phthisical cases.

2. That, as a remedial agent in consumption, it will bear no comparison
with cod-liver oil. — Med. Times and Gaz., June 27, 1857.

31. Electricity in the Suppression of the Lacteal Secretion. — M. Becqcerel, in
a late communication to the Societe Medicale des Hopitaux de Paris, has made
some remarks upon the influence of electricity in restoring the secretion of
milk. His attention was called to the subject by a case related to him by M.
Aubert, who had employed electricity in the case of a young woman whose
milk had been suppressed in consequence of a double pneumonia. The elec-
tricity was applied to the breasts by means of moist excitors, and after four
applications, each lasting twenty minutes, the lacteal secretion was completely
restored. M. Becquerel was at first incredulous as to the reality of the result;
but the following case, which fell under his observation, removed his doubts: —

A young woman, aged twenty-seven, well formed, although of a nervous tem-
perament, had suckled a young infant for six months, but, on the occasion of

522

Progress of the Medical Sciences.

[Oct.

some intense and often-repeated mental emotions, the lacteal secretion dimi-
nished considerably ; the right breast retained a little milk, but the left was
almost completely dried up. M. Becquerel applied the electrical current at
first to the left breast, placing the moist excitors, made of sponge, successively
in the different points of the circumference of the breast, so that the currents
might traverse the organ in all directions. Three applications were made,
each lasting a quarter of an hour. The patient suffered very little, and indeed
experienced little more than a feeling of inconvenience. From the time of the
first application, the rush of milk supervened almost immediately after the ap-
plication of the electrical currents. After the third application, the secretion
was full and entire ; the child had taken the breast, and the milk was abund-
ant in the left breast, and sufficient in the right to obviate the necessity of ap-
plying the electricity on that side. — Dublin Hospital Gazette, July 10, from
_Z7 Union Medicate, Jan. 3, 1857.

SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE

SURGERY.

32. Hereditary Transmission of Tendencies to Cancerous and other Tumours. — -
Dr. James Paget has made some interesting statistical investigations concern-
ing the hereditary transmission of cancerous and other diseases.

Of 411 patients which he has tabulated, 244 had cancerous, alias, malignant
tumours ; 147 had non-cancerous, alias innocent tumours ; and 10 had non-
cancerous, but recurring tumours.

Among the 254 with cancers, 60, or 23.6 per cent, had relatives of the same
or former generations with cancerous or other tumours.

Among the 147 with tumours neither cancerous nor recurring, 27, or 18.3
per cent, had such relatives with cancerous or other tumours.

Among the ten with recurring tumours, 4, or 40 per cent, had relatives with
cancers.

According to these numbers, the respective hereditary tendencies to can-
cerous and to non-cancerous tumours would seem not very different. But an
examination of the second and third tables discovers a great contrast between
them.

Among the 60 cancerous patients whose relatives had tumours, not less than
57 had cancerous relatives ; but among the 27 patients with tumours neither
cancerous nor recurring, there were only 12 who had relatives with tumours
like their own. The comparison of the respective probabilities of hereditary
transmission would, therefore, be as 22.4 for the cancerous to 8.2 for the non-
cancerous.

The contrast appears the stronger in sight of the fact that the greater part
of the instances in which similar innocent tumours occurred in more than one
member of the same family were limited to one kind of tumour. Of the 12
patients who had relatives with innocent tumours like their own, 7 had some
form of cutaneous cyst of the scalp, leaving only 5, or 3.4 per cent., as marking
the probability of hereditary transmission in all the other forms of innocent
tumours reckoned together.

It is hence certain that cancerous disease, or a tendency to it, is prone to
pass by inheritance from parent to offspring, and to occur (probably by inherit-
ance of common properties) in many members of the same family and gene-
ration. It may seem unnecessary to bring evidence of a fact so generally
believed ; but there are some who doubt it, and many who are not aware of
the large proportion of cases in which cancer may be referred to an hereditary
origin. Moreover, a comparison shows, by the contrast of the two groups of
cases, the cancerous and the non-cancerous, how many instances of apparently
hereditary origin of the disease may be referred to accidental coincidence, or
to the transmission, not of a diathesis, but of some peculiarity of the structure

1857.]

Surgery.

523

or composition of a part. When, for example, the child of a cancerous parent
has a sebaceous cyst in the scalp, we can only count it as an accidental coin-
cidence ; but the cases of this kind are not very uncommon ; and it might be
right to endeavour to estimate from them a deduction to be made in the
reckoning of the proportion of actually inherited cancers. For if, thus, dis-
similar tumours may accidentally occur in members of the same family, so, in
a certain number of cases, the occurrence of similar tumours in the same family
may be referred to accident. However, as the deduction to be made on this
ground can scarcely be calculated, and would certainly be less than the addi-
tion that we should have to make if we could reckon the cases of inheritance
from patients with unknown internal cancers, I omit it, and thus sum up the
general conclusions to be drawn from the tables.

Per cent.

Of patients with non-cancerous tumours, the proportion that has, or
has had, relatives with tumours like their own, is . . . . 8.2

Do. with tumours non-cancerous, but unlike their own . . .4.

Do. with cancerous tumours 6.8

Of patients with cancerous tumours the proportion that has, or has
had, relation with cancers, is1 22.4

Do. with non-cancerous tumours, is 1.

Of patients with recurring non-cancerous tumours the proportion
that has, or has had, relatives with cancers, is . . . .40.

A few words may be added concerning the last-named cases. The number
of instances of these recurring tumours, which occur in the members of can-
cerous families, justifies an opinion which I have long entertained, but which
it is very difficult to establish, namely, that such tumours often represent what
may be called a gradual fading of the cancerous diathesis. The cases which I
have tabulated are only those which I have seen ; but I have heard and read
of others like them, and believe that time will prove that, among the offspring
of cancerous patients, and among the members of families in which cancer has
occurred, there is a peculiar liability to the production of tumours, which will
recur after repeated and complete excisions, though they are neither cancerous
in structure, nor attended with similar disease in the lymphatics or other
organs, nor with any cachexia but such as may be ascribed to their gradual
influence on the constitution.

If this can be proved, we may justly hold that this character of recurrence
indicates the existence of the cancerous diathesis, either with less abundance
or with less concentration of material than is required for the production of a
cancerous tumour with all the typical properties.

The imperfection of the diathesis may in some cases indicate its progressive,
but as yet incomplete, development ; but the probability that, in other cases,
the diathesis is decreasing in hereditary transmission, is supported by facts in
the history of other diseases. Thus, we know many of the liabilities of the
offspring of gouty, and of phthisical, and of insane persons, and that their
diseases, though they may be neither gout, nor phthisis, nor insanity, are yet
of the same kinds, essentially the same diseases, but less manifested; or of
the same type, but less strongly marked ; and we know that success in the
management of these diseases depends, in great measure, on a due recognition
of their parentage. Now, the recurring tumours, I believe, illustrate the same
principle in the pathology of cancers ; and if so, they deserve the closest study,
as being palpable examples that, in the hereditary transmission of morbid con-
ditions, there is a tendency towards their becoming less, a tendency towards

1 This is a larger proportion than is stated in my lectures. The difference is pro-
bably due to my having here reckoned scarcely any cases besides those of patients
whom 1 have seen, while in the Lectures I referred to cases collected from various
sources. I have, probably, inquired with more than ordinary care into the family
histories of patients, but I have not questioned cancerous patients more closely or
more generally upon this point than I have those with other tumours. On the other
hand, I have not reckoned as patients having no relatives with tumours those in whose
cases I have recorded nothing concerning their families.

524

Progress of the Medical Sciences.

[Oct.

health.1 This may be due either to dilution, or to changes comparable with
those which restore an individual from disease to health ; and very probably it
is an example of that general law, according to which the deviations from the
true specific form and composition, which constitute varieties in species, become
in successive generations gradually less, till the perfect specific characters are
regained.

In practice, the recognition of recurring tumours suggests caution in speak-
ing of what may follow the removal of any tumours from persons of cancerous
family. And this caution should be the greater, the more the removed tumours
deviate from the ordinary characters of innocent growths or of the fully deve-
loped natural structures. I think that the non-cancerous tumours most likely
to recur are those which, at whatever date of growth, have structures similar
to those of the natural parts in their very early embryonic state. Such are
recurring fibroid, composed almost wholly of elongated fibro-cells, and the re-
curring fibro-cellular, cartilaginous, and mammary-glandular, in all of which
we find abundant soft or liquid transparent blastema, in which the proper
structures, when they are to be found at all, lie loose and disorderly in their
most immature forms. Indeed, whether there be any suspicion of cancerous
inheritance or not, all such soft tumours with imperfect embryo structures may
be regarded with fear of their recurrence after excision. — Med. Times and Gaz.,
Aug 22, 1857.

33. Fracture of the Thigh for the fourth time at the same part. — Sarah Hales,
aged 60, a stout, rather pale, but not unhealthy woman, in 1847 caught her
foot in the carpet and fell, breaking her left thigh-bone a little above the knee.
In seven weeks she was allowed to get up, and in twelve weeks could walk
again. In 1850, her foot slipped on a potato, and she again fell, breaking the
bone at the same part. In six weeks it was united, and in eleven weeks she
was able to get about. In 1852, when raising herself from the floor, her hand
slipped, and falling upon that knee the bone was broken at the same place for
the third time. She was able to walk in about the same time as before. In
January, 1856, when walking along the road her foot slipped and she fell, the
thigh-bone giving way for the fourth time at the same part. Whether the bone
gave way before she fell, or whether it was broken by the fall she could not
tell. She had not much pain, but knew the limb was broken because she had
lost the use of it. She was brought to Cambridge the next day; and, when
examined, the fractured portions of the bone, which were thickened a little,
could be rubbed together as though the ends were rounded and smooth. This
gave scarcely any pain, and there was very little swelling or bruising. Mr.
Humphry was apprehensive, from this condition of the part, that union would
not take place. To give it every chance, the limb was carefully splinted, and
perfect rest secured by gum-chalk bandages, etc., which were kept on for
eighteen weeks, when, firm union having taken place, she was allowed to get
up and go on crutches. These have been some time laid aside, and she can
walk without them. The bone is firmly united. There is a little overlapping,
but not much thickening. — Brit. Med. Joum., June 6, 1857.

34. Spontaneous Fracture of both Thigh-Bones. — Sophia Low, aged 56, was
admitted into Addenbrooke's Hospital, Cambridge, under the care of Mr. G.
M. Humphry, April 23, 1857. The following is taken chiefly from her own
account : She was a healthy-looking person. She said that her right thigh was
broken May 5, 1855, under the following peculiar circumstances. For some
years her leg had been subject to pain, chiefly about the middle of the thigh,
but extending upwards and downwards from that point. A month before it
broke, the pain became more severe, and she raised her leg from the ground
with difficulty. Two days before it broke she caught her toe when going up
stairs : this caused sharp pain at the middle of the thigh, and a lump formed
there. She was walking out when it seemed as though the left foot caught,

1 I think, too, that the histories of rodent ulcers, and of lupus, should be studied
with a similar suspicion of their relationship to cancers.

1857.]

Surgery.

525

and she fell ; but she is sure that she felt the right leg break "before she reached
the ground. The fracture was treated by a surgeon with splints, etc. It was
united in five weeks, so that the splints were removed and the limb gradually
got strong again. Since then she had had no more pain in the thigh ; and she
was well till soon after last Christmas, when a pain, similar to that she had
before experienced in the right thigh, affected the other limb. It got gradually
worse. In the last two or three days before the thigh-bone broke the pain was
very acute, and the limb was in much the same state as the other had pre-
viously been before the fracture of it; so much so that she feared it would
break. It did so on March 1 in the same way as the other had done. She
"kind of made a stumble, and felt it break before she reached the ground/'
Long splints, etc., were applied in the hospital. The fracture united in the
usual time, and is now quite firm. There is no pain now in the thigh ; but
she is complaining of pain in both her arms, a little below the shoulders. —
Ibid.

35. Fracture of the Humerus from Muscular Action. — Fracture of the shaft
of a bone by muscular action in a healthy person is rare, and its occurrence
has even been doubted. Mr. Henry Smith records [Med. Times and Gaz., July
25, 1857) the following interesting example of it: —

He was called -to a gentleman 20 years of age who had received some serious
injury of the arm twenty hours before. There was immense swelling about
the shoulder, but no distortion or shortening of the limb. The patient was so
exquisitely sensitive to pain, that it was impossible to ascertain the exact nature
of the injury; he was, therefore, placed under the influence of chloroform.
Notwithstanding the amount of swelling, it was pretty clear that the head of
the humerus was in the glenoid cavity, and, on careful examination, it was
discovered that the shaft of the bone was broken at the surgical neck.

It appears that the patient, while walking by the side of the river Thames,
took up a stone weighing about two ounces, and endeavoured to throw it across
the river ; he used an extraordinary amount of exertion, and just as he had his
arm extended and was about to deliver the stone, the limb dropped and he be-
came faint. He was soon seen by two medical men, who were somewhat puz-
zled as to the exact nature of the injury. One of them thought that the head
of the humerus was dislocated, and the other was of opinion that a fracture
had taken place, but they could not quite determine which had occurred.

On making further inquiry, I ascertained that this gentleman was in perfect
health, was endowed with remarkable muscular power and agility, displayed
in wrestling and rowing ; had never shown any weakness in his osseous sys-
tem ; had never had syphilis, or suffered from pains in his limbs.

The limb was put up in the ordinary manner, and a good union has oc-
curred.

Mr. S. also notices two somewhat analogous cases. In the first, a man about
25, the son of a master bricklayer, came to me with a fracture of the middle
of the shaft of the humerus, which happened while he was endeavouring to
lift himself from the ground by grasping with his hand the top of a wall. Now,
this patient told me that for some time previously he had suffered from what
are termed rheumatic pains in his arm. *

In the other case, the patient was a healthy gentleman, who had his right
humerus broken in the following way : He was attempting to force down the
arm of another man, their hands being clasped and their elbows resting on the
table. My patient, feeling that he was getting the better of his antagonist,
made an extra effort, and in so doing his arm broke just above the elbow. Un-
fortunately the nature of the accident was mistaken, and three persons were
pulling him about for half an hour before I saw him, to reduce a supposed dis-
location of the elbow-joint. This patient was a perfectly healthy man of great
muscular power. In both cases speedy and perfect bony union took place.

36. Excision of the Head of the Thigh-bone. — Mr. Alex. Ure recently read a
paper on this subject before the Harveian Society. He considers that morbus

526

Progress of the Medical Sciences.

[Oct.

coxarius commences, in the majority of instances, in the head of the thigh-
bone ; that its origin is inflammatory, and may be usually traced to a mechani-
cal injury of the great trochanter ; and that it occurs chiefly in young individuals
whose system is under the influence of a scrofulous or tubercular taint. In
those cases of the disease in which there is no prospect of a natural cure, and
the constitutional powers of the patient are rapidly yielding to the effects of
the disease — when successive collections of pus are forming in and around the
joint — where the eroded articular cartilage causes acute pain on the slightest
movement of the limb, and the patient lies in a helpless state, with the thigh
bent on the pelvis and the leg bent on the thigh ; in such cases Mr. Ure con-
ceives that the surgeon is justified in removing the head and neck of the thigh-
bone. In so doing, he merely imitates what nature occasionally accomplishes
by the so-called process of interstitial absorption. It is true that the cotyloid
cavity is often extensively diseased as well as the head of the femur, but most
frequently the erosion is confined to the upper and back part of the cavity, and
may be readily gouged out. Mr. Ure related a case in illustration of his re-
marks ; it was that of a boy, aged 5 years, of a puny and emaciated appearance,
who had been suffering from hip disease for the three preceding years. Over
the right trochanter there was an unhealthy-looking ulcer of the size of a florin,
which was continuous with a sinuous cavity of considerable magnitude, dis-
charging blood with pus upon slight pressure. On examining the rectum, a
round and smooth opening was detected communicating with the sinuous cavity
just described. All other measures having failed, Mr. Ure determined to resort
to excision of the head of the thigh-bone. He made a curvilinear incision
about three and a half inches in length, skirting along the upper and posterior
border of the great trochanter, keeping clear of the sciatic nerve. He then
divided the soft parts over the head of the femur, which was found unattached
to the cotyloid cavity, the capsular and the round ligament having been de-
stroyed. Having isolated the head and neck of the bone, he cut through the
latter at its base with bone-pliers, and withdrew the excised portion without
difficulty. He finally gouged out some carious bone from the side of the tro-
chanter, and also from the upper and back part of the rim of the acetabulum.
The portion of bone removed was of a dark red colour, soft, porous, and thoroughly
carious ; the incrusting cartilage was, in a great measure, destroyed. The wound
was closed by suture, and the thigh was kept slightly bent and abducted. In
little more than six weeks after the operation, he could move about the ward on
crutches, and bend the thigh with the pelvis fixed ; the amount of shortening of
the limb was but trifling. In the act of progression, he just put the toes and then
the heel to the ground. There were two small fistulous openings, from which
a small quantity of matter issued in the course of a day. He had gained flesh
and strength, his countenance had become cheerful, and his complexion greatly
improved. The amendment which had followed the operation was, on the
whole, very remarkable. — Med. Times and Gaz., Aug. 8, 1857.

37. Mr. Fergusson's Case of Excision of an Enlarged Third Lobe of the Pros-
tate.— This case, an account of which was given in our preceding number, p. 257,
we learn from a late No. (May 23) of the Medical Times and Gazette, terminated
fatally. The operation was performed on the 11th April. Ten days after the
patient sank into a feeble state, and continued gradually to decline until the
30th, when death took place. The autopsy showed the bladder congested,
hypertrophied, and much inflamed. Its mucous membrane was coated by
thick flakes of adherent false membrane. The wound was wanting in action,
but not otherwise unhealthy. It would, of course, be unauthorized to infer
that the bold practice adopted had any material influence on the result. Ac-
cording to the facts furnished by the Statistical Reports of operations in the
London hospitals during the last four years, at least half of the lithotomies in
adults end fatally. Whether in a case of greatly enlarged third lobe of the
prostate the impediment thus offered to the complete evacuation of the bladder,
in case it were left, or the increased size of the wound made were it removed,
would be likely to exercise the more prejudicial influence on the result, will
probably be a question upon which opinions will not differ. Granting, how-

1857.]

Surgery.

527

ever, that the immediate danger of an operation would be somewhat augmented
by such a procedure, we yet have the great subsequent advantage, should
the case do well, to fall back upon. Apart from the inconveniences and
dangers of enlarged prostate in itself, there can be no doubt but that the
risk of a second calculous formation would not have been inconsiderable. In
Mr. Fergusson's case a deep lesion was formed behind it, and in this any little
fragments of stone which had been broken off would have been almost sure
to remain, and might very probably become the nuclei of future ones.

38. Treatment of Hydrarthrosis of the Knee-joint by puncture and injection of
Iodine. — Dr. Robt. L. Macdonnell states (The Medical Chronicle, June, 1857)
that he has treated successfully five cases of hydrarthrosis of the knee-joint by
puncture and injection of iodine.

" Many/' he says, " of those who object to this plan of treatment, do so
under an erroneous idea of the nature of the disease for which it is recom-
mended, and also of the results that are expected to be derived from it. Thus,
we find some who have written and spoken against it, confounding simple
chronic hydrarthrosis with white swelling (tumeur blanche), and objecting to
the injection of a dropsical joint, because the treatment did not succeed in a
completely disorganized and suppurating articulation. Now, I would wish it
to be distinctly understood, that it is to pure uncomplicated chronic hydrops of
the knee-joint, that my suggestions as yet apply; for I have not employed the
treatment in any other joint, and though I do not believe that injection of
iodine would do any harm to a joint already destroyed by ulceration, yet I wish
the point to be clearly understood, that it is not in such affections I recommend
it. It has also been stated that serious consequences must necessarily follow
the mere puncture of so large a joint, and a fortiori, the injection of it with
iodine, or any other irritating substance, must be extremely dangerous. I shall
not here occupy my reader's time in proving the difference, as to consequence,
between the puncture of a joint in its physiological condition and a similar
wound inflicted upon it in its pathological state. Until the surgeon shall have
acquired clear and distinct ideas on this point of practice, he cannot under-
stand the rationale of injections into joints, the seats of chronic synovial effu-
sions; nor of incisions into large and small joints already in a state of suppu-
ration, as recommended by Gay and others, and which (as regards the smaller
joints) I have myself often performed.

" There is another objection urged against this practice, founded on the sup-
position that excessive inflammatory action must necessarily follow the injec-
tion, and that anchylosis or even the death of the patient might ensue. In this,
as in other instances, one fact is worth a hundred theories. Puncture and
injection have been performed not only without bad consequences, but with the
greatest success ; therefore, to discuss this point any further would be fruitless.
But some of the opposition to the practice may be ascribed to the views of Bon-
net himself, and to his method of operating. He injected the joint, with the
express object of exciting an acute arthritis, which being combated in the usual
manner, led to the removal of diseased action from the articulation, and no
steps were taken to prevent this excessive inflammatory process. Now, it is
evident that, as in hydrocele, the radical cure is often effected, not by inducing
violent inflammation of the sac, but by modifying its diseased secreting action,
so we should endeavour to induce merely a slight change of action in the sy-
novial lining of the joint; and adhere, as closely as possible, to the rule laid
down by Velpeau and Cabaret to procure in shut cavities, containing effused
fluid, an irritation which should be constantly adhesive and never purulent."

" By the method which I recommend, the fluid is forced upwards from the
articulation to the synovial bag above the joint lying on the anterior surface of
the femur, and when the fluid is withdrawn and only half an ounce of iodine
solution injected, the opposed surfaces of the sac are brought into contact and
retained in that position by the gentle and equable pressure of a well applied
wet bandage. By this means, air is prevented entering the joint, the injected
fluid is spread out evenly over the whole synovial surface, and becomes still
more diluted by admixture with the secretions of the parts, and a healthy action

528

Progress of the Medical Sciences.

[Oct.

taking place, excess of exudation and engorgement is prevented, and it is not
unlikely that adhesion occurs in the opposed surfaces of the dilated pouch in
front of the femur. This result is still further favoured by retaining the joint
in an immovable position by bandaging it to a strait splint, and by keeping the
patient upon cooling diet. Bonnet recommends us to push the trocar down in
a perpendicular direction from the front of the tumour till it strikes the femur.
I see no advantage in piercing the synovial membrane in two places, and in
wounding the femur ; nor have I followed his other direction to inject a quan-
tity of iodine solution, equal to the amount of fluid drawn off. In my practice,
I have thrown in only two drachms of strong tincture mixed with two of luke-
warm water.

" In conclusion, I would wish it to be understood, that I do not advise the
above line of treatment to be pursued, except in simple uncomplicated hydrar-
throsis, that has resisted all other remedies, and that has led to loss of use of
the limb, or has prevented the patient earning a livelihood, and enfeebled his
constitution by protracted suffering."

39. Tracheotomy in Croup. — The medical officers of the Hopital des Enfans have
long advocated an early performance of the operation of tracheotomy in croup ;
and M. Andre, one of the internes of that institution, has just published an
account of the operations performed during 1856. The following table exhibits
the results according to age : —

Age. Total. Deaths. Recoveries.

Boys. Girls. Boys. Girls.

15 months to 2 years G ... 2 ... 4 ... — ... —

2 to 3 years 9 ... 4 ... 3 ... 2 ... —

3 to 4 " 13 ... 5 ... 4 ... 4 ... —

4 to 5 " 11 ... 6 ... 3 ... 1 ... 1

5 to 6 « ........ 6 ... 3 ... 1 ... 1 ... 1

6 to 6J- " ....... 3 ... 1 ... 1 ... — ... 1

7 years 2 ... — ... 1 ... — ... 1

8 " . 2 — 1 ... 1 ... —

9 " 1 — — ... 1 ... —

»J " ... _ ... i

54 21 18 10 5

Thus it will be seen that a considerable proportion of the cases were suc-
cessful, and that this has been so in proportion as the children have been ad-
vanced in age. In all the children of less than two years of age, the operation
proved fatal ; and the others who succumbed, with two exceptions, scarcely
exceeded that age. In the two older children (seven and eight years of age)
who died, there were other causes of death independently of the operation.
The explanation of this circumstance, M. Andre supposes to exist in the fact
that children of four years of age, who recover more frequently than younger
children, offer greater resistance to both the accidents of the operation itself,
such as hemorrhage and traumatic fever, to the diphtheritis, and the compli-
cating affections, such as capillary bronchitis and pneumonia. They are also
more docile, and allow more readily of the repeated examinations of the wound
and canula that are necessary ; while suitable diet, so essential, and so difficult
of management in very young children that have been operated upon, is more
easily regulated. It is probably also due to the greater power of resistance
possessed by boys, that the proportion of their recoveries exceeds that of the
girls. Another circumstance to be mentioned, is the deplorable facility with
which children who have not already had the measles or scarlatina contract
these affections upon admission into the hospital ; and although, usually, erup-
tive fevers are uncommon prior to the fifth year, scarlatina attacked no less
than ten of these little patients, of whom a third part died. M. Andre agrees
in the justice of the opinion long held by the officers of the hospital, that the
ulterior success of tracheotomy is much interfered with by the earlier employ-
ment of debilitating remedies, such as venesection, leeches, blisters, &c. — Brit-
ish and Foreign Medico- Chirurgical Review, July, 1857, from Bull, de The'rap.

1857.]

Surgery.

529

40. Treatment of Hydrocele in Children. — M. Kichard, while attending for
M. Guersant at the Hopital des Enfans, met with no less than twelve cases of
this affection in the course of one month ; and although accident may have led
to this accumulation, he yet believes that it is of more common occurrence than
is usually supposed.

The hydrocele of children is commonly termed congenital, and as in the great
majority of cases the vaginalis communicates with the peritoneum, congenital
persistence seems to be one of the conditions of the disease. Not that all these
serous collections can be reduced by the hand, for it is more common to find
them irreducible ; but nearly all of them, if watched sufficiently long, are found
appearing and disappearing, increasing and diminishing, from time to time.
Of these twelve cases, two only were purely funicular, the ten others invading
the scrotum and cord. The cysts of the cord, which often simulate a third
testis, are in children and adolescents developed in the funicular portion of the
persistent vaginalis ; while in the adults we observe cysts of the epididymis,
containing a turbid fluid and spermatozoa.

Experience has shown that, in the treatment of these hydroceles, the persist-
ence of the communication with the peritoneum is not of the importance that
might have been expected. M. Richard's cases are treated in the following
manner: 1. The liquid is evacuated to the last drop by means of a short ex-
ploratory trocar, of very small calibre. 2. An assistant exerts compression
upon the lower part of the belly and the track of the inguinal canal. 3. From
six to seven grammes of alcohol (40° of Beaume's areometer) are then thrown in.
4. The canula is suddenly withdrawn so as to leave the fluid in the sac ; and
after continuing compression over the inguinal canal for a minute, the opera-
tion is concluded. The consequences are very simple. The tumour increases
a little towards evening, becomes a little painful next day, after when all pain
entirely ceases. From the tenth to the fifteenth day, the tumour entirely dis-
appears, and the child is cured. If he is of an age to admit of it, he is allowed
to walk or play about after the operation. Sometimes, at the instant of with-
drawing the canula, owing to the strong contraction of the cremaster and dar-
tos, a little of the injected fluid is expelled, the little patient being at the same
time seized with erection, or even expelling his feces. But this is of no conse-
quence. Sometimes, however, a few drops of the fluid enter between the skin
and the vaginalis. This is followed by redness of the skin, and the formation
of a small abscess which bursts of its own accord, without interfering with the
progress of the cure. The smallest possible trocar must be employed in this
delicate operation, although, without practice, such an instrument is more dif-
ficult to use. We must render the hydrocele very tense with the left hand,
isolating it as much as possible, and holding the trocar in the right hand, apply
the pulp of the thumb and the index finger very near the pointed extremity of
the instrument. In place of thrusting this in, as in the adult, we must insinuate
its point as if using a bistoury. When the cure has been obtained, a good
precaution consists in wearing an inguinal bandage for three or four months ;
for a principal advantage of the operation for congenital hydrocele, is derived
from the protection it affords against the production of hernia. — British and
Foreign Medico- Chirurgical Review, July, 1857, from Gazette des Hopitaux, No.
41, 1857.

41. Enucleation Treatment of Uterine Fibrous Tumours. — Mr. J. Hutchinson
has given {Med. Times and Gaz., Aug. 8 and 15, 1857) an interesting report on
this subject. The following are his conclusions: —

" 1. That surgical interference with interstitial fibrous tumours of the uterus
is always attended with very considerable risk, and ought not to be practised
except under circumstances of urgency, or when the position of the growth is
peculiarly tempting.

2. That when the tumour is not of very large size, and is already partially
extruded, the operation is rendered comparatively devoid of danger, and ought
to be performed at once.

3. When the tumour is yet wholly imbedded, and even when of large size,
No. LX VIII— Oct. 1857. 85

530

Progress of the Medical Sciences.

[Oct.

the enucleation treatment is yet warrantable if the patient's life be threatened
by hemorrhage.

4. That primary enucleation, where at all easily practicable, is much prefer-
able to the secondary method.

5. That where the tumour is very large, or where found after the incisions
to be firmly united to its capsule, the secondary plan should be preferred.

6. That whichever plan it is intended to adopt, the first incision should, ex-
cepting under unusual circumstances, be made from within the cavity of the
cervix, and should be as free as possible.

7. That the danger of hemorrhage from this incision is very slight indeed.

8. That as much should be done as practicable at the first operation in the
way of freeing the tumour from its cyst. Thus, if the adhesion be found more
loose than had been expected, a primary enucleation may be completed where
the slower plan had been proposed.

9. That the after-treatment in cases of primary enucleation should consist
in warding off the shock by opiates, in sustaining the strength, and in the free
use of stimuli and nutritious diet.

10. That in cases of secondary enucleation, the ergot of rye should be ad-
ministered, so as to keep up vigorous uterine action, that the greatest attention
should be paid to sustaining the patient's strength, and to the removal of dis-
charge and shreds of slough as fast as formed.

11. That in cases of great exhaustion and threatened pelvic inflammation,
the internal use of turpentine is of great value.

12. That in cases of secondary enucleation the surgeon need not be anxious
about the removal of the tumour en masse, but may entertain a good confidence
that if it have taken on a sloughy state in its lower part that the death and
piecemeal disintegration of the whole will follow.

13. That the " recurrent fibroid" tumours slough away yet more readily after
interference than the true fibrous ones, although liable to return after a short
interval of health.

14. That after a successful enucleation procedure, complete, though gradual,
restoration to good health may be expected."

42. Ovariotomy. — Dr. Charles Clay, of Manchester, states {Edinburgh Med.
Journal, June, 1857), that he has performed this operation in 79 cases, of which
24 terminated fatally, and 55 in recovery.

43. Concretions of the Prostate. — Mr. H. Thompson read before the Royal
Med. and Chirurg. Soc. (June 9th) a paper on the concretions of the prostate,
their mode of production, and their relation to the formation of prostatic cal-
culi— the result of observations made upon upwards of fifty dissections of the
prostate.

The existence of " concretions" of microscopic size has been established in
every one of the fifty specimens of the prostate exhibited. In many, their size
was that of a poppy-seed. They had been found, also, in the organ at 14 years
of age. Their physical and chemical characters (the latter by rigid analysis)
were given at considerable length. Their existence was concluded to be a
necessary result of the performance of natural functions on the part of the pros-
tate. After numerous observations, it appeared that the formation of a concre-
tion frequently originated in the aggregation of a yellowish matter, often seen
within the secreting nuclei lining the gland-ducts and pouches, often found free
in yellowish granules, sometimes stuffing small ducts and follicles, and seen
floating in the form of small prostatic fluid, as well as in the contents of the
vesiculae seminale3. In the larger masses of this yellow matter, entirely occu-
pying the interior of crypts or follicles, the small granules may be seen coher-
ing, or as if fusing together, and presenting an appearance identical with that
which is often seen existing in the centre of fully formed concretions. It was
concluded that the coalescence of these yellow granules, or of the nuclei charged
with them, their partial fusion into a mass more or less homogeneous, the stra-
tification in part of this mass itself, or more probably the deposit upon its sur-
face of fresh layers of fluid matter similar to that which originally constituted

1857.]

Surgery.

531

the interior, and finally, some addition of opaque earthy matter to it, either by
infiltration or accretion (through irritation of the secreting membrane around,
from the pressure of the newly-formed body, as observed in numerous other
instances referred to), were the steps by which the production of a " prostatic
concretion" was very frequently accomplished, and its connection with "pros-
tatic calculus" illustrated. The views of other observers were quoted and dis-
cussed at considerable length. Numerous drawings of these bodies in various
stages of formation, as well as the original objects themselves, under micro-
scopes, illustrated the communication.

44. Gonorrhoea of the Nose. — Mr. Edwards records [Lancet, April 4, 1857) a
case of this in a respectable widow, produced by her using a handkerchief for
her nose, which her son, who was labouring under gonorrhoea, had employed
to suspend his testicles.

45. New Crimean Tourniquet. — Mr. Salt objects to the ordinary tourniquet,
especially in military use, on account of the liability of the pads and straps to
become saturated and clotted with

blood ; and to Skey's and Signorini's
tourniquets on account of their com-
plexity and costliness. He describes
one devised by himself, which consists
of an ordinary stay busk of sufficient
length to embrace the largest limb,
and by a series of notches at both ex-
tremities may be so reduced as to fit
the smallest. It is coated with elastic
gum, smoothly polished, so that it
may be kept clean simply by the use
of a sponge and warm water. The
limb being embraced by the tourni-
quet, all that is necessary is to direct
pressure upon the artery by a few
turns of the screw.

The following are stated to be the
advantages of the instrument : —

1. It has no detached parts ; is
adapted for any sized limb ; and may
be applied instantaneously.

2. It yields equally to the action of
the screw, concentrates the pressure
upon the artery, and does not inter-
fere with the venous circulation.

3. It dispenses with all straps, buckles, and other adjuncts; and is available
at any moment, and for any number of cases. — Assoc. Med. Journal, Nov. 29,
1856.

New Crimean Tourniquet.

46. Rectangular Catheter Staff for Lithotomy. — Mr. Hutchinson read before
the Royal Medical and Chirurgical Society (Feb. 10, 1857) an account of a
rectangular staff for lithotomy. The main peculiarities of the instrument were
its rectangular form and its catheter stem. The advantages of its form were,
1st, that it made the direction into the bladder straight, and thus obviated all
danger of the knife leaving the groove ; 2dly, that the angle projecting promi-
nently into the perineum was more easily found than the curve of an ordinary
instrument ; 3dly, that its groove commencing only at the angle, there was no
chance of the urethra being opened too far forward, or the artery of the bulb
being wounded ; 4thly, that when once introduced it did not easily change
position. Its being a catheter as well as a staff was important ; 1st, because it
allowed the surgeon to be quite certain of its being really in the bladder before
commencing the operation ; 2dly, because it permitted of the bladder being in-
jected without any change of instruments, and thus prevented the risk of the

532

Progress of the Medical Sciences.

[Oct.

water escaping. It was provided with a stopcock. The author insisted strongly
on the importance of operating with a full bladder and the dangers of its
neglect, and believed that one great recommendation of his instrument was,
that it would much encourage and facilitate the practice. Adverting to the
causes of accidents in lithotomy, he stated, that of a series (nine) which had
come under his notice during the last few years, chiefly in the practice of the
London Hospitals, they had been due to, 1st, the knife leaving the groove in
the staff; 2dly, the staff being at the time not really in the bladder; 3dly, in-
jury of the fundus of the bladder with the point of the knife ; and expressed a
strong opinion that the employment of the " rectangular catheter-staff" would
have prevented them all. The instrument shown to the Society had a side
groove, and was adapted for the use of any form of knife the operator might
prefer. It had been made by Messrs. Fergusson, of Giltspur Street. It had
been tried in the deadhouse a great number of times, and once upon the living
subject, and always without any inconvenience. There was no difficulty what-
ever in its introduction. It was advised to be held in the usual way, mode-
rately hooked up under the symphysis pubis, but by a slight movement of the
handle its angle might be made to project more or less into the perineum,
according to the operator's wish. Mr. Hutchinson wished distinctly to state
that he made no claim to originality of design. Dr. Buchanan, of Glasgow,
had long ago recommended and used an angular staff for lithotomy, and more
recently Mr. Fergusson had devised a grooved catheter for perineal section.
The present instrument was merely a combination of the two principles. He
believed, however, that it possessed in its catheter stem a very important ad-
vantage over Dr. Buchanan's, since it enabled the operator to ascertain with
positiveness whether he was in the bladder. With instruments of the ordinary
curve this is done by striking the stone, but as an angular one is very incon-
venient for sounding, it is liable, when made solid, to the objection that the
surgeon might occasionally have to operate in uncertainty. The author also
laid before the Society several other modifications of the angular staff which he
had had made in the course of a long series of experiments as to the safest
instruments for lithotomy. One of these had the groove beneath, and the knife
adapted to it was a double cutting gorget, the beak of which was so made that
when once placed it could not leave the groove. This he had once used on the
living without inconvenience ; but as it was liable to some objection, and as
the side groove allowed of the operation being completed by a single knife, and
much simplified the apparatus, he had at length abandoned the principle
which distinguished the former.

Mr. Spencer Wells said the rectangular staff had been described eight or
nine years ago by Dr. Andrew Buchanan, of Glasgow, in a Scotch journal.
That gentleman laid especial weight upon the point, that in his operation the
staff should be pressed downwards, and not drawn upwards, so that the rectum,
instead of being drawn into danger, might be pressed out of it. The project-
ing angle of the staff was brought very near the anus in the median line, and
the forefinger of the left hand passed into the rectum to feel the apex of the
prostate, taking care that the projecting angle was immediately in front of,
and not behind, the prostate. Dr. Buchanan made a very different incision
from that made in the ordinary lateral operation. The knife was passed into
the groove of the staff, directly in front of the anus, and held horizontally, as
if the operator were going to cut towards the tuberosity of the ischium, and in
withdrawing the knife it was brought out downwards, so that the incision re-
sembled one-half of the incision made by Dupuytren in his bilateral operation,
except that it was much nearer the anus. In this way Dr. Buchanan con-
sidered that the rectum could not be injured. In his (Mr. Wells's) experiments
on dead subjects, he had found that unless the assistant was careful, and the
surgeon also, the angle of the staff was apt to slip into the bladder, and the
prostate was pushed forwards towards the perineum ; and thus the bladder
was opened either through the substance of the prostate or behind it, the old
operation of cutting upon the gripe being thus performed. This was likely to
take place unless great care was taken to feel with the forefinger in the rectum
that the angle of the staff was made to rest exactly at the apex of the prostate ;

1857.]

Ophthalmology.

533

in fact, that the prostate was between the finger and the horizontal branch of
the staff.

Mr. Erichsen said that he thought Mr. Hutchinson's staff likely to prove of
considerable value. He could give no opinion as to the merit of the rectangu-
lar shape, having had no experience of it, but he thought the combination of
the catheter with the staff peculiarly valuable ; it enabled the surgeon to in-
spect the bladder without changing instruments, prevented the escape of the
injected fluid, that was apt to ensue between the withdrawal of the ordinary
catheter and the introduction of the staff, and would tend to prevent some of
the accidents that might befall a surgeon in lithotomy. Had he been provided
with such an instrument, an accident that had once occurred to him might
have been avoided. A patient was sent to him with stone in the bladder,
which was at once detected on sounding. When about to be cut, the staff was
introduced, apparently into the bladder, but no stone could be felt. A hollow
sound, with a- short beak, was then passed, and the calculus at once struck.
The staff was again introduced, and, as it passed without difficulty of any kind,
and the point could be felt on depressing the handle above the pubes, it was
supposed by Mr. Erichsen and those assisting him that it was in the bladder;
but that, having a large curve, the stone probably lay in this. Mr. Erichsen
proceeded to cut the patient, and, on opening the groove of the staff, found it
was not in the bladder. Having satisfied himself of this, he withdrew the
staff, and passed the hollow sound, -with which he had previously felt the
stone, cut upon this, and extracted a large calculus. The patient unfortu-
nately died, and after death three old false passages were found leading from
the urethra into the abdominal space, and by the side of the bladder. It was
into one of these that the staff had passed, but the sound being larger, and
having a short beak, escaped it, and entered the bladder. Now, had the staff
been hollow, as in Mr. Hutchinson's instrument, such an event could at once
have been recognized by the non-escape of urine. Since this case had occur-
red, Mr. Erichsen had heard of several instances in which a similar accident
bad happened. This led to the inference that the proper rule of practice
should be, to feel the stone with the staff rather than with a sound when the
patient was on the table. He did not know whether the use of the hollow staff
in perineal section originated with Mr. Fergusson or Mr. Thompson, but he
had used the instrument with great advantage during the past twelve months.

OPHTHALMOLOGY.

47. Amaurosis with Bright' s Disease of the Kidney. — The connection between
these two diseases was pointed out nearly about the same time by Landouzi,
of Rheims [U Union Medicate), and by the editor of this Journal [Proceedings
of Philad. Coll. of Phys.).

Mr. Holmes Coote, in a recent paper on this subject [British Medical Journal,
April 25, 1857), remarks: —

" When the kidneys are so diseased that the proper urinary excretion is im-
paired, and the effect is felt in the general constitution of the blood, the walls,
not only of the larger arteries, but likewise of the capillaries, undergo a mole-
cular or granular degeneration, by which they lose their elasticity and strength,
and are very liable to give way. In the examination of the bodies of persons
who have died under these circumstances, I have found in the brain four, or
even more, small extravasations of blood in the various stages between recent
effusion and complete repair. The same morbid changes occur, I believe, in
the arteries of the choroid, retina, and vitreous humour, where they give rise
to changes which impair or destroy vision, and may be recognized during life."

''Although Blodig found only three cases of this combination of amaurosis
and Bright's disease of the kidney during the five years he studied in the

534

Progress of the Medical Sciences.

[Oct.

Ophthalmic Clinic of Vienna, I believe it will be found of more general occur-
rence, not, perhaps, always manifested by sudden loss of vision from the rup-
ture of diseased capillaries and the effusion of blood, but by changes dependent
on the disturbed circulation through vessels which have lost their elasticity and
power of regulating the flow of blood through tissues perhaps the most delicate
in the human body — changes which, though slow, are not the less sure to ter-
minate in the disorganization of those parts upon which depends the suscepti-
bility to the impressions of light. Thus, Dr. Heymann, of Dresden, found, in
one case of similar nature, turbidity of the vitreous humour; in another, a
sort of serous swelling of the optic nerve papilla ; in another case, the retina
was covered ' as if by a cicatrix/ I found, in a case recently examined, loss
of brilliancy in the choroid, absence of defined arrangement of the arterial
capillaries. The vessels brought into view appeared to be venous, and were
tortuous and varicose."

48. Diphtheritic Ophthalmia. By MM. Warlomont and Testelin. — This
article constitutes one of the additional chapters its authors have contributed
to their translation of the last edition of Mackenzie's treatise On Diseases of
the Eye. A form of pseudo-membranous ophthalmia was, they say, indicated
by Bovisson, of Montpellier, in 1847 ; and M. Chassaignac has alluded to the
pseudo-membranes which occur in the ophthalmia of new-born infants; but
the present affection has been particularly described by Gr'afe, of Berlin, the
disease, indeed, thus far, seeming peculiar to Germany.

Symptoms. — In an eye in its normal state, but more frequently in one that
has already suffered from inflammation, great irritation is suddenly set up,
accompanied by much tumefaction of the conjunctiva, an inconsiderable amount
of chemosis taking place. A network of large vessels ramifies over the con-
junctiva, and the membrane itself, of a yellowish colour, is marbled over by a
great number of minute red points. If an incision be made into the chemosis,
fluid does not flow out, the submucous tissue being infiltrated with gelatini-
form fibrin. The upper eyelid is remarkably tense, and so much pain does its
eversion produce, that Gr'afe resorts first to chloroform. When the conjunctiva
is thus exposed, it presents a polished yellowish colour, which is due to a
fibrinous exudation that penetrates into its substance, and leads to arrest in
the circulation. The exudation can only be detached from the membrane with
difficulty. It may be well seen by causing the patient to look downwards, and
by everting the superior eyelid sufficiently to see the oculo-palpebral fold. The
lower eyelid is also rigid, but little movable, and very red. Besides the symp-
toms mentioned, there are two others — a great and continuous increase of tem-
perature, and an abundant discharge of a dirty gray fluid, carrying with it
yellowish flocculi. This condition, which constitutes the first stage of the
affection, continues for a longer or shorter period; and the diphtheritic process
may still be going on after the original swelling of the eyelid has diminished.

After awhile, the rigidity of the eyelids disappears, and the conjunctiva as-
sumes a spongy appearance, abundant fibrinous masses becoming detached
from its surface. In parts, it may retain its habitual colour, while in other
places, the exposure of the vessels gives rise to copious bleedings. The por-
tions deprived of the mucous membrane swell more and more, and assume an
appearance very like that seen in chronic blennorrhcea. There are also nume-
rous nodosities formed upon portions of the conjunctiva, which, resistent at
first, soften with the progress of the affection. The chemosis of the ocular
conjunctiva now loses its hardness and yellow colour, and a dense vascular
network is developed, so that the diagnosis of the affection at this period is
very difficult.

The third stage is characterized by retraction of the eyelid, proportionate to
the amount and depth of the original fibrous infiltration. In some patients,
day after day false membranes are removed three-quarters of a line in thick-
ness, and having a hole in the centre corresponding to the circumference of the
cornea. These are the pathognomonic signs of the affection ; but to them may
be added various degrees of opacity or ulceration of the cornea.

Nature and Causes. — As to the nature of the affection, it is derived from an

1857.]

Ophthalmology.

535

inherent disposition of the mucous membrane to take on the diphtheritic action.
It is a general disease, occurring more frequently in unhealthy than in healthy
individuals, and internal affections frequently prevail during its progress.
Thus, among forty children, the subjects of it, M. Grafe found death result in
three from croup, and in other instances from pneumonia or hydrocephalus.
It also frequently coincides with diphtheritic inflammation of the skin or aper-
tures of the mucous membranes. Eight of these forty children were the sub-
jects of congenital syphilis. When one eye is affected the other often suffers,
whatever precautions may be taken to prevent inoculation. Epidemic in-
fluences are its principal cause, for, after months have elapsed without a case
occurring, great numbers may be suddenly met with. New-born infants are
not especially predisposed to it, although in the ophthalmia they suffer from
it; a fibrinous exudation, giving a certain amount of rigidity to the eyelid,
may be observed. The affection is indubitably contagious. As already exist-
ing inflammation, especially when traumatic, predisposes to it, operations must
be abstained from when the affection prevails epidemically.

Diagnosis and Treatment. — The only affection it can well be confounded with
is gonorrhoea! ophthalmia, and the author exhibits the distinctive signs at some
length. With respect to treatment, copious depletion, by means of leeches
applied near the angle of the eye, but especially to the root of the nose, is re-
commended by M. Grafe. Ice-cold affusions are also to be frequently applied,
and the eye is to be kept scrupulously clean, for which purpose milk is one of
the best appliances. In certain forms of the disease, caustics may be required.
M. Grafe strongly recommends the energetic employment of mercury, this
being the only internal medicine of any value. The regimen must be strict,
and but little fluid should be taken. In several cases, the second eye has been
preserved from an attack by keeping it closed. — B. and F. Med.-Chir. Rev.,
J uly, 1857, from Annates d' Oculistigue.

49. Photophobia and Blepharospasm relieved by Chloroform. — Dr. Mackenzie,
of Glasgow, communicated to the Royal Med. and Chir. Soc. a case of intense
and long continued (sixteen months) photophobia and blepharospasm relieved
by the inhalation of chloroform administered seven times. Mr. Arnott stated
that he had administered this remedy in a case of strumous ophthalmia, with
intolerance of light, with not only immediate but permanent relief.

50. Hemorrhage from the Eyeball after the Extraction of Cataract — Mr. White
Cooper relates (Lancet, April 11, 1857) the following very interesting examples
of this unusual occurrence.

Case 1. On June 13, 1855, I performed extraction on the right eye of Mrs.
B., aged seventy, who had long attended as an out-patient. Each eye pre-
sented a hard, amber-coloured cataract. The globes were hard and rather
prominent; anterior chamber full ; irides natural in colour; pupils ordinarily
motionless, but dilating under atropine. She could distinguish light from
darkness, and the shadow of a hand. Some years previously she had suffered
from deep-seated pain in the eyeballs, with niuscae, and had long been teased
with irregular gout.

From the hardness of the globes, and immobility of the pupils, I thought
unfavourably of the case ; but a woman's earnest entreaties that I would, at
all events, give her the chance afforded by an operation, induced me to make
the attempt on one eye. The section was completed with facility, the curette
used, and with gentle pressure the lens escaped, a small quantity of rather
fluid vitreous humour accompanying it. The flap being replaced, the lid was
dropped, and I paused before taking a final look at the eye. After a few
seconds, the patient clapped her hand to her eye, and exclaimed, " Oh, what a
pain in my head!" Removing her hand, I looked at the lid, and saw it
rapidly becoming distended ; gently raising it to ascertain the cause of this
unlooked-for circumstance, I found the section gaping widely, and a large
mass of hyaloid pushing through it ; in a second or two, a gush of blood
poured from the eye, and flowed down the cheek.

536

Progress of the Medical Sciences.

[Oct.

I at once recognized the case as one of those generally described as rupture
of the central artery of the retina, though I may here mention that, judging
from the great flow of blood, and bearing in mind the small size of the vessel
in question, I regard the choroid as the seat of the hemorrhage ; it was pre-
cisely such a discharge of blood as I have seen when the choroid has been
wounded in removing a staphyloma, and very obstinate the bleeding may be
under those circumstances.

The remedy which I have found most useful in checking hemorrhage from
the eye is pounded ice, folded in linen and laid on the lids. Little can be
done in the way of pressure, the parts being so exquisitely sensitive that it
cannot be borne. Pounded ice was, therefore, applied to this patient's eye,
and three grains of gallic acid ordered to be taken every four hours. Not-
withstanding the steady perseverance in these measures, the bleeding con-
tinued for thirteen hours, when it gradually ceased.

On the evening of the 17th, the patient being low and faint, a cordial opiate
was administered ; yet, when the power of the circulation returned, to our
mortification, the bleeding recurred. Ice was again applied, and in half an
hour the flow of blood finally ceased.

The application of cold was persevered in for two more days, when, suppu-
ration of the globe commencing, poultices were ordered. The patient, who
had been much reduced by the loss of blood, now required liberal diet and
wine, and opiates were prescribed to allay the pain accompanying the inflam-
mation and suppuration of the globe. Under this treatment, the eye gradually
became quiet and ultimately collapsed.

The second case occurred during the last winter, and was remarkable from
the hemorrhage not taking place till ten days after the extraction.

Case 2. The patient was a feeble old woman, who had been a great sufferer
from rheumatism, and was so extremely deaf that it was with difficulty she
could be made to comprehend a single sentence addressed to her. This in-
firmity made her very nervous and unsteady during the operation (which, you
may remember, was performed on the left eye). From her extreme restless-
ness the section was made with difficulty, and the irist unavoidably wounded,
though not to any extent. The lens was extracted with facility, and there
was no escape of vitreous humour. I observed that the cut at the margin of
the pupil bled more freely than usual, but did not attach much importance to
this. Cold water dressing was applied to the eye for twenty-four hours, after
which dry dressings were used. The patient was allowed liberal diet on ac-
count of her want of power. Being anxious that every opportunity should be
afforded for firm union of the section, the eye was not disturbed till the
seventh day. On that day, however, observing a little oedema of the upper
lid, I opened the eye, remarking that there was probably serous chemosis and
non-union. There was, however, then, no chemosis ; the eye was pale, cornea
clear, but the section not united. I decided on closing the eye again for some
days, and ordered wine, with bark and ammonia. Examining the eye again
on the tenth day, the section was still open, and serous chemosis existing; a
solution of nitrate of silver was directed to be carefully applied once a day.

That evening the sister of the ward was suddenly called to this patient, and,
to use her own expression when describing it to me, " the eye appeared to be
hanging out on the cheek, with blood streaming from it." Mr. Staples was
with the patient in a few minutes, and applied ice and a compress. It was
evident that hemorrhage had taken place within the globe, pushing out the
vitreous humour, and then escaping through the section. The hemorrhage
continued actively for about an hour, then gradually ceased, and did not
return. Acute inflammation of the globe, with great swelling of the lids, fol-
lowed, and the patient became so prostrated that I was in some apprehension
as to the result. The poor woman had so fixed her mind upon dying from the
operation that, before entering the hospital, she had had her coffin made and
her funeral arranged. Happily, her forebodings were not realized, and, with
great care and attention, she gradually rallied, the eye sank and became quiet,
and she left the hospital convalescent.

The question now presents itself, are there any means of diagnosing these

1857.]

Ophthalmology.

537

hemorrhagic cases before operation ? Gentlemen, you will do well to regard
with suspicion eyes presenting the following conditions: Tense, hard globe,
traversed by purple tortuous veins; sluggish or immovable iris; with, perhaps,
one or two minute points of adhesion to the capsule of the lens ; the existence
of motes, flashes, and occasional dull aching at the back of the eye, with pains
of the brow and cheek, the patient, at some time or other, having had gouty
symptoms. You must bear in mind, however, that the pain, the muscse, and
other symptoms of disturbance, may have passed away, and will not be men-
tioned unless inquiry be made: yet their existence, in connection with the
other symptoms, often indicates a varicose state of the choroid and of the
retinal vessels, with, perhaps, degeneration of their coats.

Dr. Gairdner has pointed out that venous congestion is a common attendant
on gout; my own observation coincides with this. A patient of mine, who
lost his right eye from arthritic glaucoma, besides being a martyr to the gout
in his limbs, underwent an operation on the throat; uncontrollable venous
hemorrhage took place, and he died. A few weeks since, I removed an eye
from a patient of Dr. Gairdner's ; though the ball itself was cleanly dissected
out by means of scissors and a strabismus-hook (a proceeding which is gene-
rally almost bloodless) ; there was profuse hemorrhage at the time, and the
bleeding did not cease for three hours, in spite of the constant application of
ice ; the patient, however, recovered so rapidly that an artificial eye was intro-
duced on the seventh day, and borne perfectly well. I mention these cases
because I believe that when bleeding does take place from eyes which have
been the seat of chronic arthritic inflammation it is likely to be obstinate.

What is to be done to check the bleeding? Pounded ice to the lid, gentle
pressure if it can be borne, and gallic acid internally, are the best measures.
If the globe fills with blood it will be utterly destroyed ; but cases are recorded
where the bleeding hp*s been slight, and recovery of sight has taken place. It
is, therefore, very important to check it promptly. If the patient be old and
feeble, and the powers of life failing, stimulants, as brandy, may be absolutely
necessary ; but the less the better. The very depression of the circulation
may be the means of arresting the hemorrhage, whereas a too hasty adminis-
tration of stimuli to keep up the pulse may be the very means of defeating the
main object. The room should be kept cool, the patient be carefully watched
and kept absolutely quiet — the fewer persons admitted the better ; the alarm
and agitation of friends are an annoyance to the surgeon, and are hurtful to
the patient.

51. Ultimate III Results of the Depression of Cataract. — An instructive case
has recently been under Mr. Bowman's care in the Moorfields Ophthalmic
Hospital, in which depression had been practised with perfect success, and,
after nearly two years of good sight, the eye had been lost by inflammation.
The particulars are briefly as follows: George H., now aged 62, came up from
the country to be under Mr. Bowman's treatment for cataract, in May, 1854.
The cataract was most advanced in the left eye, in which it had existed for
about eighteen months. He was blind of the left, and the right was becoming
inconveniently misty. Mr. Bowman (who was then performing depression in
a number of cases, with the view of testing the value of this operation as com-
pared with extraction) depressed the lens in the left eye, and with perfect
success. The man soon after returned home, and for more than two years
enjoyed sight which enabled him to read the smallest print, and had no pain
whatever in the eyeball. In July, 1856, he was suddenly attacked by severe
pain in the globe, for which he could assign no cause. He describes the illness
as having been attended by much pain and feverishness, and within a week of
its commencement had lost his sight. After a time, the pain subsided to a
great extent, but he remained without any vision whatever in the affected eye.
In the mean time, the cataract in the right eye had so much increased that
he could make but little use of it. In May, of the present year, therefore, he
came in order to have a second operation performed. The lost eye was con-
stantly fretful and painful, and the lashes of the lower lid were turned against
it. Before proceeding to extract, Mr. Bowman first performed the usual opera-

538

Progress of the Medical Sciences.

[Oct.

tion for entropium, and also determined to remove the lost globe, fearing that
it might prove a source of irritation to the other. This was accordingly done,
and an opportunity thus occurred of examining the state of the organ. The
nucleus of the depressed lens was found still existing, and, although dense and
shrivelled, was not actually cretaceous. The choroid and retina had been
separated by effusion between their layers. Last week, Mr. Bowman extracted
the lens from the right eye, and when the eye was opened, a day or two since,
the section was found united, with a central clear pupil. The man has been
wearing an artificial eye with perfect comfort, from the fifth day after the ex-
cision. The readers of our notes will be aware that the operation by depres-
sion is one which is now never performed at the Moorfields Hospital. It has
been wholly discarded on account of the frequency of such occurrences as the
above case illustrates, viz., that the nucleus of the lens is liable at any subse-
quent period to become a source of irritation and excite inflammation, which
will end in amaurosis. Although so much easier of performance, and so
tempting on account of its little risk and the speed with which good vision is
obtained, it is therefore, in the long run, a much less satisfactory procedure
than extraction. We might add that the operation by solution, when the lens
is hard, is liable to nearly the same objection. The outer parts of the lens
only are really absorbed, and, after a succession of troublesome operations, the
nucleus at last drops out of the axis of vision, and a condition of things very
similar to that obtained by depression exists, and one which is liable to the
same subsequent risks. — Med. Times and Gaz., June 27, 1857.

52. Symblepharon treated successfully by Blandhi's Method. — Mr. R. Taylor
relates (British Medical Journal, June 13, 1857) the case of a lad, 15 years of
age, who applied for relief at the Central London Ophthalmic Hospital in Au-
gust, 1856. "Nearly a year and a half previously he had received a severe
injury in the right eye, and a less serious one in the left, from lime, for which
injuries he had been treated for some months at a hospital. His state, when I
first saw him, was as follows : The right eyeball and lid were united by a dense
firm cicatrix, extending nearly the whole length of the palpebral fissure, and
upwards over the cornea so as to conceal the pupil, with the exception of a small
chink, which was obscured by a faint milky opacity. Every attempt at moving
the eye was attended by a most disagreeable feeling of constriction ; and the
sight was so far impaired that he could not make out the largest print. In the
left eye the consequences of the injury were so slight as not to require surgical
interference. There were a few loose bands of adhesion at the bottom of the
palpebral sinus ; and though the lower part of the cornea was obscured by
opacity, this did not trench upon the pupil, and vision was unimpaired.

" The operation upon the right eye may be described nearly in M. Blandin's
words. The cicatrix was carefully dissected from the cornea and sclerotica in
its whole extent, until the eyeball was completely free ; and the dissection was
continued until the bottom of the palpebral sinus had been reached, and the
bony margin of the orbit could be felt with the finger. There was thus left a
broad thin flap of cicatrix adhering to the tarsal margin of the eyelid. This
was then folded in, in the manner of a hem, so that its smooth surface, which
had formerly been external, was now in apposition with the raw surface of the
eyeball, and a lining was provided for the eyelid to the very bottom of the pal-
pebral sinus. In this position the flap was retained by two sutures passing
through the entire thickness of the lid, and tied externally on the skin of the
face.

"The subsequent progress of the case may be thus condensed: One of the
sutures was, unfortunately, detached by the efforts of the patient, who did not
understand its importance; and I was not informed of the accident until it was
too late to replace it. Tne other was removed on the fifth day after the opera-
tion. The outer three-fourths of the flap adhered to its new position, leaving
a palpebral sinus of the natural depth. At the inner part there was still a nar-
row elastic band between the eyelid and the lower and inner part of the cornea;
which, however, did not interfere with the free movement of the eye. A sub-
sequent attempt to get rid of this adhesion was unsuccessful. The opacity

1857.]

Midwifery.

539

•which formerly covered the cornea has been removed, partly by operation and
partly by absorption, to such an extent that three-fourths of the pupil are now
perfectly clear; and the vision is almost, if not altogether, as good with this
eye as with the other. So little irritation was produced by the operation, that
the lad returned to his work (that of a plasterer) the day after the second suture
was removed.

"Although, owing to the unfortunate detachment of one of the sutures, the
success of this operation has not been so complete as it might otherwise have
been, still the relief afforded in a case which is universally condemned as hope-
less has been so striking that I earnestly trust that this very ingenious and
simple operation may have a further trial in this country ; this, so far as I am
aware, having been the only occasion on which it has been performed. Among
the labouring and manufacturing population, who are in an especial manner
exposed to the accidents by which symblepharon is produced, there must be
many who are suffering from all its inconveniences, who would gladly avail
themselves of any chance of relief by surgical means, and who might perhaps
ere now have been relieved, had this mode of operating been known and at-
tempted. To speak confidently, from the results of two operations (M. Blan-
din's and my own), would be premature. All I would wish to enforce is, that
the method proposed appears to be founded on just and scientific principles ;
that it is the only one hitherto proposed which is at all likely to be adopted in
this country for the relief of a very distressing affection, hitherto considered as
irremediable; and, finally, that it has proved successful in the only two in-
stances, so far as I am aware, in which it has been performed. "

[Where the adhesion is extensive, and the bands long, this operation may be
successfully resorted to ; but we have met with cases where the lid and ball
were so closely united that no flap could be made. In a case in which there
was only one narrow connecting band, we, several years since (1843), divided
the band, and united the edges of the cut on the inner surface of the lid by
suture, with the most satisfactory result. Mr. Wilde has since performed the
came operation, but brought together the edges of the conjunctiva, on the eye-
ball as well as on the eyelid, by sutures. The former, we are persuaded, is
unnecessary. — Editor.]

MIDWIFERY.

53. Use of the Speculum. — Dr. Robert Lee read before the Royal Med. and Chi-
rurg. Soc. (June 9, 1857) some further observations on the use of the speculum
in the diagnosis and treatment of uterine diseases. He referred to the tabular
statement of 220 cases of real and imaginary disease of the uterus, published
in the 38th volume of the Medico- Chirurgical Transactions, and presented in a
similar tabular form the details of eighty additional cases which had since
come under his observation. Of the 300 patients, 47 were unmarried ; one
had barely completed her 18th year, several were under 20, and the majority
under 30 years of age, and were suffering from hysteria, leucorrhoea, dysme-
norrhcea, or some nervous affection of the uterus, without inflammation, ulcera-
tion, or any structural disease or displacement of the organ. In Case 256, the
patient had been told that the womb was prolapsed and much ulcerated, and
an instrument had been introduced for six weeks, with an aggravation of all
the symptoms. The hymen was found so perfect on examination that it was
impossible to reach the os uteri without using an unjustifiable degree of vio-
lence. On the ground of morality, and on every other ground, he could see no
defence for the employment of the speculum in these 47 cases. Of the 300
patients 70 were barren, and the sterility was not removed nor the other symp-
toms relieved in a single instance. Several of these individuals spoke with
horror and shame of the treatment to which they had submitted. A consider-
able number of the cases were suffering from cancerous disease, in all of which
the symptoms seemed to have been aggravated by the treatment. In Case 236

540

Progress of the Medical Sciences.

[Oct.

the character of the disease was unmistakable, but after an examination with
the speculum a favourable prognosis had been given, and the actual cautery-
employed for months, and hopes of recovery held out to the last. The author
expressed his conviction, that neither in the living nor in the dead body had
he ever seen a case of simple ulceration from chronic inflammation of the os or
cervix uteri, and to apply the term to states of the os uteri in which the mu-
cous membrane, or, as it is termed by some, the basement membrane is not
destroyed by ulceration, was an abuse of language calculated only to deceive
and mislead the members of the medical profession, from whom the truth has
been carefully concealed. The speculum emanates from the syphilitic wards
of the hospitals at Paris, and it would have been better for the women of Eng-
land had its use been confined to those institutions. — Med. Times and Gaz.,
June 20, 1857.

54. Statistics of Coiling of the Funis. —Dr. Weidemann states that among
28,430 deliveries the funis has been found coiled around the child in 3379 in-
stances. In 3230 of these it was coiled around the neck, and in 149 around
other parts of the body. Of the 3230 cases, 2546 consisted in a simple coil,
and in 684 there were several coils. In relation to the causes of this occur-
rence, it is interesting to notice that of 1788 cases occurring at the Marburg
Midwifery Institution, the funis was in 80 (1 : 22.2) under 15 inches, and in 183
above 25 inches (1 : 9.71) in length ; that in 54 (1 : 33) there was very little liq.
amnii, and in 41. (1:43.6) there was very much; in 165 (1:10.8) the child
was under five pounds weight, and in 28 (1 : 61.7) it was above eight pounds.
Therefore, among the favouring causes of the occurrence may be mentioned a
long funis, abundance of liq. amnii, and a small child.

Among 2930 infants born at Marburg 182 (1 : 16.09) were dead, and 251
(1:12.41) were stillborn. Of 725 born with coiled funis, 45 (1: 16.11) were
dead, and 72 (1 : 10.06) were stillborn. Of the 45 dead-born, in 18 only could
the death be referred to this alone, i. e. only 1 : 40.2 in the 725 examples of
coiling. From an examination of the figures derived from the midwifery insti-
tutions at Dresden, Gottingen. Wlirzburg, Berlin, and Marburg, it results that
of 13,720 new-born infants, 902 (1: 15.21) were born dead; while in 1217 in-
stances of coiling of the funis 31 children were born dead, whose death could
be attributed to that circumstance, giving a proportion of 1 : 39 to the coilings,
and 1 : 19 to the number born dead.

Thus, as (1) the 16th child among new-born children in general, as well as
among those in which coiling has taken place, is born dead ; as (2) the 12th
child among the new-born in general, and the 10th among those around whom
the funis is coiled is born stillborn ; and as (3) in 1 child in 40 only can this
coiling be regarded as really the cause of death, it is evident that this accident
does not occupy a very prominent place. — Med. Times and Gaz., July 18, 1857,
from Monatschrift fur Geburtskunde, Bd. viii.

55. Statistics of Placenta Prcevia. — Dr. Schwarz, of Fulda, in Hesse-Cassel,
having heard the frequency of placenta prsevia stated in a medical society as
far greater than he had hitherto believed it to be, examined in reference to this
point the official returns made by the Hesse practitioners. These were sup-
plied by 150 accoucheurs, during a period of 20 years, i. e. from 1835 to 1854
inclusive. They related to 519,328 births, and among these were only 332
cases of placenta pnevia — the numbers varying from 8 to 28 per annum. Of
these 332 cases, 246 women recovered and 86 died : 251 children were born
dead, and 85 were born living. In 40 instances the women were primiparous,
and in 292 pluriparous. Podalic version was performed in 259 cases, and
cephalic version in 7 ; while in 23 instances the children were removed by the
forceps, in 6 by craniotcmy, and in 13 by post-mortem Cgesarean section. In
8 instances the placenta was removed, and in 16 the plug was resorted to. —
Med. Times and Gaz., May 30, 1857, from Monatsch. fur Geburtskunde. Bd. viii.

56. Sudden Death after Parturition, with Air in the Veins. — By Geo. May,
Jr., Esq. That death may result from the entrance of air into the veins during

1857.]

Midwifery.

541

surgical operations, has long been known to the profession ; but that it might
be a cause of danger after parturition (as suggested by Legallois in 1829), did
not obtain the notice it deserved, until Dr. Cormack read a paper on the subject
before the Westminster Medical Society in 1850. I propose to allude briefly
to the cases narrated by Dr. Cormack, and then to give the details of three
that have occurred in this neighborhood.

In 1841, Dr. Bessems attended a labour, in which there was hemorrhage
with retention of placenta. On the fourth day after her confinement, whilst
an injection was being thrown into the uterus, she suddenly exclaimed that
she was suffocated, and died in three minutes. Air was found in the heart
and veins.

M. Lionet, of Corbeil, attended a lady, aged 27. She was much frightened
during the last month of pregnancy, and did not completely recover her
strength ; but. her labour was natural, and not attended with hemorrhage. She
soon, however, became faint, breathed with difficulty, and expired five hours
after delivery. Air was found in the heart and in the cerebral veins.

Dr. Wintrich, in 1848, published a case of rapid death after parturition.
Convulsive movements and suffocation followed the expulsion of the infant and
partial separation of the placenta. Air was found in the venous system.

Professor Simpson mentions a case in which death occurred a few hours
after a delivery,- accompanied with hemorrhage and alternate contractions and
relaxations of the uterus. Air was found to have entered through the uterine
veins.

Dr. Lever mentions three cases ; in all of them there was hemorrhage, and
death a few hours after labour. Air was found in the uterine and other veins.

In 1850, Mr. Berry, of Birmingham, attended a primipara, aged 22. There
was little hemorrhage, and she appeared to be going on well for six hours ;
she then became affected with difficulty of breathing and faintness, and expired
in less than an hour. Air was found in the heart. The uterine veins were
patulous.

Case I. — The case of which an abstract is here given, was read before the
Reading Pathological Society, by Mr. Taylor, of Wargrave.

In September, 1841, Mrs. , aged 30, was taken in labour with her third

child. The labour progressed naturally ; but no urine having been passed,
Mr. Taylor was in the act of introducing a catheter, when a severe pain occur-
red. The liquor amnii was discharged to the amount of three-fourths of a pint.
The woman suddenly exclaimed, "Oh ! how faint I feel," was convulsed for a
moment, and then expired. By the last pain, the head had been forced partly
from the outlet. An attempt was made to remove the child without success.

A post-mortem examination was made forty-eight hours after death. The
uterus extended above the umbilicus. The placenta occupied the anterior
surface from pubis to umbilicus ; no portion was separated. A few days before
her labour, she had a copious discharge of blood. There was little blood in
the uterus. The bladder was empty. The lower vena cava was empty. The
heart was healthy. The right auricle was thin, almost transparent, and dis-
tended with air. Hardly a trace of blood existed in the heart. The brain and
membranes were healthy. In the spine, between the theca and the cord, there
was considerable effusion of fluid blood, but none within the sheath.

Case II. — I am indebted to Mr. Smith, of Whitchurch, for the details of the
following case: —

Mrs. T., between 38 and 40 years of age, was confined of her sixth child, a
male, on the morning of May 7, 1852, about 8 A. M., and her attendant left
her shortly afterwards, as he said, very comfortable. As, however, she had
severe after-pains, an opiate was sent her. Mr. Smith was summoned to her
about 2 P. M.; and on his arrival, he found she had just died. She complained
of excessively severe after-pains, together with great oppression about the
chest, and feelings of sinking and exhaustion and extreme restlessness. In
answer to inquiries as to whether there had been any hemorrhage, the attend-
ants stated that there had not.

A post-mortem examination was performed the same evening, the body not
being quite cold. The abdominal viscera were all free from disease. On

542

Progress of the Medical Sciences.

[Oct.

opening the uterus, which was large, there was found a considerable quantity
of coagulated blood ; but not by any means enough to satisfy one that loss of
blood was the cause of death. The uterus contained also a considerable piece
of the placenta adhering to its internal surface. In the chest were old adhe-
sions between the pleura costalis and pulmonalis. The heart appeared
distended ; not that it was enlarged, properly so called, but that it had an
appearance of distension, which was evidently on the right side of the organ.
On opening the right auricle, a quantity of air escaped with a sort of little puff,
and the organ was at once reduced to its proper dimensions. No disease was
found in its substance or valves. The left ventricle contained a small clot.

Case III. — In the autumn of 1855, Mrs. E., aged 28, was delivered of her
third child, after a natural labour. She had become sufficiently convalescent
to resume her household duties ; but on the eighth day, she was taken sud-
denly ill, and expired before Mr. Walford arrived.

I assisted at the post-mortem examination the following day. No unusual
appearance was observed, until the liver was sliced ; it was then noticed that
frothy blood escaped, and, a further examination being made, air was dis-
covered in the vena cava inferior and vena portse ; and the right side of the
heart was distended with frothy blood. The uterus was of its usual size for
the eighth day. There was no sign of decomposition about the body.

Remarks. — It does not appear to be generally admitted that the entrance of
air through the uterine sinuses can cause death ; but if we recollect that Dr.
Cless, of Stutgard, examined the bodies of 1,200 patients, who had died of
various diseases, without finding air in the heart; that in the eleven cases
here alluded to, death was more or less sudden, and could be explained by no
post-mortem appearances ; that the development of gas from putrefaction was
quite out of the question, some of the bodies being warm at the time of exami-
nation ; and that these cases present an analogy with those in which air enters
the veins during operations and experiments ; I think we are forced to the
conclusion that the entrance of air through the uterine veins was the cause of
death.

I will, however, shortly send some examples to prove that the local genera-
tion of air may in some cases prove fatal. — British Med. Journal, June 6, 1857.

MEDICAL JURISPRUDENCE AND TOXICOLOGY.

57. Partial Paralysis of the Extremities, caused by the continued Use of Snuff
containing Lead. — In the year 1854, Dr. Moritz Meyer, of Berlin, published a
case of lead paralysis, caused by the long-continued use of snuff containing
lead. In this case he employed electricity both as a diagnostic and a thera-
peutic means.

The subject of the disease was a furrier, aged 38 ; he had experienced weak-
ness of both hands and inability to move them well; but for three months
before he was seen by Dr. M. he had completely lost the power of extending
the hands. He was otherwise healthy, but his complexion was of a sallow hue.
The paralytic symptoms were not preceded by any abnormal sensations except
slight dragging pains of both shoulders. A powerful electric stream directed
along the course of the extensors did not throw them into action. The electro-
muscular sensibility of the paralyzed parts was diminished, so much so that a
strong current was scarcely perceived.

The treatment employed in this case, which was clearly one of lead para-
lysis, consisted in the protracted use of electricity, sulphureous baths, and
saline purgatives. The recovery was slow, but the cure was complete. The
use of the snuff was abandoned as soon as the cause of the disease was dis-
covered.

The snuff was (Pariser No. 2, manufactured by Bernard of Offenbach)
packed in lead, and the patient, who purchased it by the pound, preserved it
in the leaden envelop.

1857.]

Medical Jurisprudence and Toxicology.

543

As far as Dr. Meyer knows, no case resembling this has been since commu-
nicated, and having since encountered three others he considers it his duty to
make them known, believing that the chronic lead poisoning is not unfre-
quently produced in the manner alluded to.

The second case was a man aged 43, who, since 1845, had been in the habit
of taking snuff packed in lead (Pariser No. 3). After having suffered for
months from painful distension of the abdomen, especially in the umbilical
region, he was seized in December, 1851, with a severe attack of colic and con-
stipation, which lasted for six days. The like symptoms returned ; the colour
of the skin assumed a yellowish tinge, and great difficulty of digestion existed.
In 1852 and 1853 the gentleman was sent to Carlsbad, but soon after his return
in October he was again attacked by colic — again in the following February,
and this attack was accompanied with paralysis of the first two, and afterwards
of the other fingers of the right hand, and finally of both arms. He was first
seen by Dr. Meyer in the July of 1855 ; he was then emaciated, anaemic, and
of a yellowish waxy hue. The gums had receded from the upper teeth. The
muscles of the arm were wasted. Extension was impossible. The electro-
muscular contractility and sensibility of the extensors remarkably diminished.
After the employment of sulphureous baths, saline purgatives, and the daily
use of electricity for six weeks, there was a manifest improvement. The pa-
tient was able to raise his arm from the shoulder-joint, but extension of the
wrist was still impossible. His appearance and his spirits had also undergone
a favourable change. The power of the muscles gradually returned, and he
was able to write. In the month of May, 1856, recovery was complete.

The third case was that of an advocate, in whom the paralysis was far more
advanced than in the others. He was born in 1814, and at the age of 27 he
began to take snuff abundantly. According to his own statement, he used
" Pariser No. 3" uninterruptedly, which he preserved in the leaden envelop
for the purpose of keeping it moist. After five years (1846) gastric symptoms
appeared with fever, distension of the abdomen, pain with colic, and obstinate
constipation. He also suffered from loss of appetite and want of sleep.

The skin and the sclerotic gradually assumed a yellowish colour, the hands
began to tremble, and in the year 1851 this increased so much that he could
not write.

In the autumn of 1852, after an attack of colic of great severity, both upper
extremities became completely paralyzed.

In the year 1854, after another severe attack, the lower extremities also were
affected in the like manner, having previously been affected with spasms. The
Marienbad waters, &c, had the effect of removing the paralysis of the lower
extremities, and the following year having learned the injurious effect of the
snuff he ceased to use it. Nevertheless, in July, 1856, he presented a misera-
ble appearance ; the muscles of the arm were lax ; the forearm like that of a
skeleton; extension of the wrists and fingers impossible, the latter could be
separated only very slightly from the palms of the hands. The face presented
the aspect of saturnine poisoning. The electro-muscular sensibility was di-
minished in the extensors.

In the course of six weeks, during which the paralyzed muscles were daily
electrified, the patient was able to extend the wrist-joints, especially the right,
and was able to separate the fingers from the palm of the hand to the extent
of three or four inches ; the reaction of the paralyzed muscles had materially
improved. At this period the patient passed from under Dr. Meyer's ob-
servation.

The fourth case was presented in the person of a gentleman formerly himself
a practising physician, Dr. Kaehler, aged 45, who for the first time suffered
six years since from frequent pains in the recti muscles, with painful disten-
sion of the abdomen, and a sensation in the left hand like the creeping of ants.
This patient presented all the symptoms noted in the former cases in a high
degree, but the constipation was more obstinate than in any of the other cases.
He derived such benefit from iron baths and from the use of the Driburg
waters, that he expected a lasting cure by these means, but the improvement
was only temporary — the symptoms returned. However, on giving up the use

544

Progress of the Medical Sciences.

[Oct.

of the snuff, and having recourse to sulphureous baths and the Bitterwassa of
Plilna for six weeks, he experienced a marked improvement. The steady ap-
plication of electricity completed the cure in this case also. The blue line of
Burton was observed in the gums of this gentleman.

Dr. Meyer observes that in these four eases of saturnine poisoning by snuff
there existed — 1, perfect integrity of the supinators, with more or less complete
paralysis of the extensors ; 2, the arching forward of the metacarpal bones ;
and 3d, the yellowish faded hue of the face. In three cases repeated attacks
of colic preceded the paralysis; in one they were entirely absent. In three
cases the common extensors of the fingers had chiefly suffered; in one the
deltoid.

The four persons whose cases are detailed had all taken the snuff which is
most in use, " Repe der Gebr. Bernard in Offenbach."

It now remained to prove the presence of lead in their snuff and compare it
with others. The examination was performed by Simon of Berlin.

The result proved the presence of lead in the snuff, 0.78 to 1.78 per cent. ;
it also appeared that the intervention of blotting-paper did not prevent the
snuff becoming impregnated with the lead; moreover, that the use of tin-foil
(staniol) was no protection, inasmuch as it frequently contained lead.

The addition of a solution of common salt, which is used for the purpose of
moistening the snuff, promotes the solution of the lead and consequent con-
tamination.— Dublin Hospital Gazette, July 15, 1857, from Archiv J'dr Patlio-
logische Anatomie und Physiologie und far Klinische Med.

[Another case of slow poisoning by lead contained in snuff, will be found re-
corded at p. 406-7 of this number.]

58. Death from Amylene. — Dr. J. Snow records [Med. Times and Gaz., Aug. 8,
1857) the particulars of a second death from amylene. It occurred in St.
George's Hospital, July 30th, in a case in which "Mr. Caasar Hawkins removed
a small epithelial tumour from the back. The patient, a short, muscular man,
was a tailor, 24 years of age, who had been in the hospital several months,
and had had three similar tumours removed, by as many operations, under
chloroform ; the last of these operations having been performed three weeks
previously. He inhaled the amylene without any difficulty ; in about two
minutes he appeared to be unconscious, and, in another minute, the sensibility
of the margin of the eyelids was somewhat diminished, and I told Mr. Haw-
kins that he might perform the operation. For this purpose the patient, who
had been lying on his side on the table, was turned a little more on his face,
or at least it was attempted to turn him, when he burst out into a kind of hys-
terical excitement, laughed loudly, and was with difficulty held on the table.
Nothing was done during this excitement, which lasted about a minute. After
it had subsided, I administered a little more amylene, although the patient had
not recovered his consciousness ; and then Mr. Hawkins performed the opera-
tion, which I believe did not last more than two minutes altogether. During
the operation the patient was turned on his face. He rested, I think, chiefly
on his knees and elbows. He was muttering in an incoherent manner, and
making slight attempts to move, but was easily restrained. I gave him an
inspiration or two of amylene now and then during the operation, with the
intention of preventing his waking prematurely ; for this purpose I turned the
head a little to one side, and raised the face a little from the table.1 I had
concluded that the patient would not require any more amylene, and was ex-
pecting that he would show signs of returning consciousness or sensibility
almost as soon as Mr. Hawkins had tied the suture which he was introducing;
but, instead of this, the limbs became relaxed, and the breathing, though free
enough, took on a noisy, snoring character. a

This is a state which is common enough in the use of chloroform, and ex-
cites no alarm whatever, but I felt that it ought not to occur in the use of amy-
lene, especially after it was left off. I therefore sought again for the pulse at
the wrist, and could perceive it only with difficulty, if at all. I spoke to Mr.

1 Less than an ounce of amylene was poured out, and it was not all used.

1857.]

Medical Jurisprudence and Toxicology.

545

Hawkins, and we immediately turned the patient on his back. His face had
already become livid, and his breathing was of a gasping character. Mouth
to mouth insufflation of the lungs was performed, and between the insufflations
there were spontaneous acts of inspiration, during which the air seemed to
enter the lungs freely. In a minute or two the lips became of a proper colour,
and the countenance had altogether such a natural aspect that the patient
seemed to be recovering. The pulse at the wrist, however, could not be felt.
No one listened to the chest at this time, for fear of interrupting the process
of artificial respiration. After two or three minutes, Dr. Marshall Hall's me-
thod of artificial breathing was substituted for the insufflation, and it was con-
tinued very perfectly by the House Surgeons and others for an hour and a half,
with the exception of two short intermissions, which will be mentioned.
During three-quarters of an hour of this time there were spontaneous inspira-
tions, during which air entered the lungs, in addition to that which entered
during the turning process. Twenty minutes after the accident, the process of
artificial respiration was suspended for about a quarter of a minute, to enable
me to listen to the chest. I thought I could hear the heart beating regularly,
but very feebly, and certainly there was a good vesicular murmur, and the
air seemed to enter the lungs by the patient's own breathing, almost as freely
as in health. At the end of three-quarters of an hour, with the permission of
Mr. Hawkins, I introduced two harelip pins which had been connected with
the electro-magnetic battery, with the intention of performing galvano-puncture
of the heart. The needles were introduced to the depth of about an inch and
a half between the cartilages of the ribs, just to the left of the sternum, and
on a level with the nipple. They were afterwards found to have penetrated
the walls of the left ventricle, near the septum, but without reaching the
cavity. There was a quivering contraction of the pectoral muscle when the
needles were first applied, but no effect on the heart. The needles ought pro-
bably to have been coated with some non-conducting substance almost as far
as their points. There were no further efforts of inspiration after this time,
but this was probably only a coincidence. The electro-magnetic battery had
been applied in the early part of the treatment by means of the wet sponges
applied to each side of the chest, but it produced no effect.

An examination of the body was made by Mr. Holmes, the Curator of the
Hospital Museun:, on the following day. A good deal of dark-coloured fluid
blood flowed from the right cavities of the heart, and the left cavities contained
but little blood. The heart was pale and somewhat friable ; but a microscopic
examination by Mr. Holmes did not show any fatty degeneration. The lungs
were moderately vascular, and contained some small epithelial tumours of the
same character as those removed from the back. There was a large cyst in
one kidney, but, with these exceptions, the organs were healthy. The vessels
of the brain were not distended, and that organ was altogether less vascular
than is usual after sudden death. No smell of amylene was perceived in the
body."

The accident in this case, Mr. Snow thinks, clearly commenced in the heart;
the brain, he says, was never more than partially under the influence of the
amylene; its fatal action was undoubtedly exerted on the nerves of the heart.

59. Trial of Miss Madeleine Smith. — The case of Madeleine Smith is in every
aspect of it the most extraordinary in the annals of criminal judicature. Not
even extending our review to an age so remote as that of the Marchioness de
Brinvilliers do we recall a case presenting, on the hypothesis of guilt, a mys-
tery of human nature so astounding, or upon the hypothesis of innocence, a
problem of circumstantial evidence so perplexing. A young lady, while yet a
girl — not yet 20 years of age — was supposed to have ruthlessly poisoned her
lover; not for forsaking her — that would have been comparatively a common
case — but to get rid of him, in fact, for loving her "not wisely, but too well."
Women have often slain their lovers for infidelity ; but this would have been
the first recorded case in which the gentle heart of woman so steeled itself
against affection as to be capable of murdering an ardent lover, merely in
order to be relieved from his attachment.
No. LXVIIL— Oct. 1857. 36

546

Progress of the Medical Sciences.

[Oct.

Of course the theory of the prosecutor suggested a motive, to meet this
moral difficulty. The suggestion was that she had sacrificed him to interest,
and that she had got rid of him because he was in the way of her union with
a richer lover. This would have been without much moral probability, for
although, alas ! men have often sacrificed affection to expediency, such is not
the nature of woman. But the suggestion was involved in this difficulty; that
the supposed victim was the favoured lover; that the other had been previously
known by the young lady ; that she had preferred the secret rival ; and that
her acceptance of the other had rather been in deference to the wishes of her
parents. So that the suggested solution of the moral difficulty only raised a
greater ; for we were to suppose a girl murdering her favourite lover in order
to facilitate her union with one to whom she had preferred him, but her anxiety
for her marriage with whom was supposed to be so great, that, though it had
I not been sufficient to prevent her from falling in love with another, it was
powerful enough to induce her to murder that other and favoured lover!

To meet this difficulty another theory was suggested — that she murdered him
from fear of exposure. Having, it was urged, at last accepted the first known
lover, and having had secret interviews and clandestine correspondence with
the other, she was anxious to prevent that exposure which his jealousy had
threatened. And this theory it was sought to support by her own confession,
that she had sent for him to persuade him to give up her letters. But then,
again, this theory was also fraught with difficulties greater than that which it
was proposed to meet ; for as her letters were in his possession, and she had
no access to his residence, and had never been there, and had no acquaintance
with any of his connections, on his death they must infallibly, as, in fact, they
did, fall into the hands of strangers. Moreover, if the intimacy had stopped
short of what was criminal, the utmost that could be exposed was a foolish
love affair, which a fond parent or an attached lover might easily pardon ; and
if it had gone to the extent of what was criminal, then there was a probable
contingency in the event of which his death would have been her utter ruin.

These were the anterior moral difficulties raised by the theory of guilt. The
evidence raised other improbabilities quite as puzzling. The theory of the
prosecution was that on several previous occasions she had administered poi-
son to her lover, and in this extraordinary way : their meetings were secret, in
her father's house (or rather at her father's door), at the dead of night; and
she is supposed to have given him once or twice before the fatal occasion a cup
of cocoa drugged with arsenic. It is supposed, further, that he suffered se-
verely on these occasions — that he suspected the draughts he had received from
her — that he had even expressed his suspicions to a third party — and that, not-
withstanding all this, he went again to a stolen interview, drank again from
the drugged, and this time the fatal, cup, and fell a victim to his fond infatua-
tion. Surely if this were so, the case is, in that aspect alone, without a paral-
lel. That a man should, almost knowingly, take poison from the hands of his
mistress, involves, indeed, an infatuation which could hardly have been con-
ceived by the wildest imagination. She purchased poison ; she was in a state
of frenzy ; it could only have been for her lover. Such was the case for the
prosecution. But do girls in frenzy never poison themselves ? Her letters
certainly show this to have been more probable than murder.

The surrounding circumstances of what is supposed to have been the actual
deed of murder raised other difficulties in detail quite as insuperable. It was
proved that on the 4th of March she had written to him, advising him to go
away to the south of England. The poison she purchased (as it is suggested)
for this last and fatal draught was bought on the 6th, the very day she went
away herself from Glasgow for a week or two. On her return he went away,
and was away on the 21st March. The night of Sunday, the 22d March, was
the fatal time. On the Friday she did not know he was away, and wrote,
making an appointment for the Saturday night. That appointment, which was
couched in the most endearing terms, he did not and could not keep, because,
being away from Glasgow, he did not get it until the Sunday. The whole
strength of the case for the prosecution on this, the very gist of the case, was
rested on the fact, that nevertheless, he at once proceeded to Glasgow, as it is

1857.]

Medical Jurisprudence and Toxicology.

517

suggested, for the purpose of visiting his lover, and that he was seen near her
house that fatal night, but as early as nine o'clock; and then, as the evidence
for the prosecution showed, he was in quest of some one else, on whom he ac-
tually called, and whom he much wished to see. But the night constable, who
had seen him on former occasions near to, and at the house of his lover's
father, did not see him there on that night. So that while, on the one hand,
he was not proved to have been at her house on that night, his being in the
neighbourhood was otherwise and naturally accounted for. Nor was this all.
He had not kept the appointment conveyed to him for Saturday. She did not
know the reason — that he was away from home — and therefore there was no-
thing to lead her to expect him on the Sunday night. On that night she went
to bed about eleven o'clock (when he was seen in the vicinity it was two hours
before) — and with a younger sister who slept with her. There the evidence
left her, and left him, for several hours.

At half-past' two on that fatal night or morning, he staggered to his door,
labouring under the first effects of poisoning by arsenic ; for eight hours he
suffered agonies, during which he never alluded to any administration of poi-
son, and after his death he was found to have received some quantity of arsenic,
which could hardly have been less than 160 grains, for upwards of 80 were
actuallyjbund in his stomach, and might have been even more than that quan-
tity ; three or four grains being sufficient to destroy life.

The theory for the prosecution was, that in that interval, between eleven and
half-past two, the whole of the dread tragedy of crime had been acted ; that
the lover had come to the door of his beloved ; that he had managed to awaken
her without disturbing the family; or that she, without knowing that he was
coming, had craftily risen for him so soon as her sister slept ; that she had
then prepared the deadly draught, boiling the arsenic with the cocoa — (for the
chemists said that would be necessary to absorb so large a quantity without
certainty of detection by the party drinking it), and that then she had induced
her lover, for the third or at least the second time, to take from her hands, at
that unseasonable hour, under such suspicious circumstances, the same sort of
draught which he had before suspected to be poison; and which he could
hardly have avoided suspecting to be poison again ! And that then, having
given him the fatal dose, she had conversed with him until the first effects
began to display uhemselves ; had then dismissed him with the usual blandish-
ments to go and writhe a few hours in quiet and unaccusing agony, and die ;
and that she then again undressed and went to bed with her young sister, who
found her next morning there as usual, and with calm and tranquil counte-
nance accompanied her to the family breakfast table !

Surely such a combination of improbabilities — of almost impossibilities —
required stringent proof ; and the Lord Advocate declared that in this case
" there was not a link wanting in the evidence ;" that "there was no loophole
at which the unhappy prisoner could escape." Such was certainly not the
opinion of the legal profession in this country, nor, as we are informed, in
Scotland. And that was rather reckless language to be used by the first law
officer of the Crown, in a case of life and death ; it was language which should
hardly be used if the case was clear and cogent. But was this such a case ?
The case of a girl, accused of poisoning her lover — a man who was not proved
to have been with her on the fatal occasion! Circumstantial evidence must
often be resorted to, and inferences must be drawn from facts. But the infer-
ence of guilt must arise from the facts proved. And here,, even if the man had
been seen at the house on that night — the reception of the poison could only
have been an inference. Then, however, it would have been an inference from
a fact; here it was sought to make an inference upon an inference — nay, rather
against the facts. For the evidence rather tended to show that he was not
there on that night — at any such hour as is supposed ; or that if he were, she
could not have seen him. Was this a case to characterize as one in which
there was not " a link wanting/' and in which there was " no loophole for
escape ?" "VVe rejoice that the jury thought otherwise.

The Scottish law differs from ours in several points. In one, which presses
most cruelly upon the accused ; in another, which is rather in his favour.

548

Progress of the Medical Sciences.

The accused is liable to be examined previous to commitment, whereas in
England the voluntary confession of a prisoner is alone received.

In this case the first, if not the only information, on which the Crown con-
structed their whole case of a poisoning by arsenic, in the medium of cocoa,
was derived from the answers of the prisoner (which were declared to have
been singularly frank) to the questions, whether she had ever given him any-
thing to take at their interviews ? and whether she had ever purchased arsenic ?
There were some irregularities — observed upon by the Court — in the manner
of taking the evidence of the only witness (Miss Perry), who at ail connected
arsenic with the administration of cocoa by the prisoner; and she stated that
the deceased had complained to her that he had been ill after he took cocoa
from " her," which was explained to mean the accused, although he did not
name her. Now as this was the solitary piece of evidence which bore at all
strongly on the accused, and as it appeared that on one point — an important
point of date — Miss Perry was enabled to correct her evidence by a suggestion
from the official examining her, we should like to know whether, when she
made that statement as to the observation of deceased about cocoa received
from " her," Miss Perry had been informed or allowed to gather that the ac-
cused had acknowledged the administration of cocoa, and the purchase of
arsenic! If so, then — as we all know how quickly, especially under excite-
ment, the mind will weave inferences to mislead the memory — probably the
testimony of Miss Perry, which told so terribly against the accused, might
have been a mere error; and, anyhow, it illustrates the fearful peril which
attends the practice of a compulsory examination of an accused party.

The other point of Scotch law to which we refer is, that the jury are not
bound to find the prisoner " guilty" or "not guilty," but they may simply say
" not proven." At first sight this might seem an advantage to the accused
party, as compared with the English system, but perhaps practically it is little,
if any, for the English jury must be unanimous ; which always secures the
accused the benefit of a doubt. On the other hand, the Scottish verdict not
proven" leaves a painful doubt on the character of the accused ; and we are
surprised that in this case the verdict of "Not Guilty" was not recorded on
all the counts, for we cannot help thinking that the hypothesis of guilt is en-
compassed with difficulties actually insuperable; and so widely do we differ
with the Lord Advocate, that so far from thinking that there was no link
wanting in the evidence, we really do not see any link in it to connect the
accused with the catastrophe, except that "link" which was supplied by the
evidence of Miss Perry, the whole strength of which was destroyed by the
strictures the Court passed upon the mode of her examination, and which in
another point of view told in favour of the prisoner.

It is indeed impossible not to see that (as we said at the outset) the hypo-
thesis of Miss Smith's innocence involves a mystery. But then it is a mystery
not necessarily associated with suspicion as to her. For the remarks we have
made (all founded on the evidence for the prosecution) go to show not only
that she was not proved to have done the dreadful deed, but that it is in the
highest degree a priori improbable, and, on the evidence, all but impossible
that she could have done it. And on the hypothesis that she did not do it, it
is not of course for her to show who did it — whether the deceased or some
other party. On that head it is enough to say that even the evidence for the
prosecution left it, to say the least, quite as probable that he poisoned himself,
as that the accused poisoned him ; and while the evidence for the defence
accounts for her purchases of poison, it raised a great probability that he also
was in possession of arsenic. Upon the other hand, the character of the man,
and the admitted fact that he was in correspondence, and on intimate terms
with other women, leaves a pretty large loophole (to use the phrase of the
Lord Advocate) for a supposition that poison might have been administered by
some other person than the accused. At all events, the evidence is consistent
with the hypothesis that some other party caused the death ; a state of things
in which, according to the doctrine of all writers on criminal jurisprudence,
the accused is entitled to an acquittal. — Evening Herald.

1857.]

549

AMERICAN INTELLIGENCE.

ORIGINAL COMMUNICATIONS.

On Starch as a Product of the Liver, and on the Amyloid Degeneration of
the Liver in Yellow Fever. By Samuel Jackson, M. D., Professor of the
Institutes of Medicine in the University of Pennsylvania.

The existence of an amyloid substance was demonstrated by Virchow and
Bennett, to be the peculiar anatouiical alteration of the liver, in many cases
designated as waxy or fatty. In alluding to this fact in my course of 1855,
the suggestion was made that the peculiar appearance of the yellow fever liver,
supposed to be a fatty degeneration, might possibly be owing to a similar
modification. The attention of the southern gentleman who would possess
the best opportunities of making the requisite observations, was invited to
this subject as an investigation of great interest. In October of that year I
had made some experiments on slices of liver, sent to me at my request, from
the Pennsylvania Hospital, taken from a patient who had died of yellow fever.
The quantity was too small for complete examination, and the commencing
alteration of the specimens rendered the results imperfect.

This prevision has been, to a certain extent, verified by my young friend
Professor Joseph Jones, of the Savannah Medical College, as will be seen in
the following extract from a letter received from him of date June 24.

"On the first of next month (July,) I expect to take charge of the Savannah
Hospital in conjunction with Dr. Arnold. My object is to investigate the phy-
sical and chemical changes of the solids and fluids in our southern bilious,
remittent and yellow fevers.

"Last summer I had the opportunity of examining several yellow fever
livers chemically. Their reactions differed from those of bilious and remittent
fevers. They contained a substance which gave reactions similar in all re-
spects to cellulose, and presented under the microscope an appearance like the
granules of starch. The reaction of the bilious fever livers also showed the
presence of cellulose, but in much smaller amount.

44 A solution of potassa readily dissolves the liver of bilious fever, but acts
very slowly on the yellow fever liver.

44 1 endeavoured to make gun cotton out of yellow fever liver. If I had
taken sufficient care, it is probable I might have succeeded. My mind, how-
ever, is not at all satisfied with these partial results, and I have not therefore
given them any publicity."

It appears to me to be no more than justice to Professor Jones to make the
above statement, as the subsequent researches of M. CI. Bernard fully sustain
his observations, while he has been anticipated by M. Pelouze. In conse-
quence of his laudable desire to present his investigations in a more complete
and authentic form, he has lost precedence in publication.

M. Ci. Bernard, in following up his important discovery of the sugar-mak-
ing function of the liver, had satisfied himself " that sugar was not an imme-
diate product of the liver derived from any element of the blood ; but that
it was constantly preceded by the creation of a special matter capable of gene-
rating sugar by a sort of secondary fermentation."

It became necessary, before further progress could be made, that this spe-

550 American Intelligence. [Oct.

cial matter should be isolated, and its nature and properties be ascertained. M.
Bernard has succeeded in accomplishing this important chemical fact, by a
most ingenious and admirably devised process and manipulation. The de-
tails of this process were communicated to the Academie des Sciences, March
23d of this year. At a subsequent meeting of the Academie, M. Bernard
communicated verbally a more simple and direct method for obtaining liver
starch than the one he had originally employed.

The glucogenic or sugar forming matter of the liver, obtained separately,
possesses all the characteristics of hydrated starch. The one of most interest,
is that relative to its change into sugar. " All the influences without a single
exception which transform vegetable starch into dextrin and glucose, equally
change the glucogenic matter of the liver into sugar passing through the in-
termediate state of dextrin."

From this important discovery by M. CI. Bernard, it results that the liver
sugar is generated by two distinct acts, the one vital or physiological ; the
other chemical. The liver starch appears to be produced by the act of nutri-
tion or the proper organic actions ; while this substance is transformed sub-
sequently into sugar under the influence of a special ferment, that is brought
to act on it in the 'liver.

At first M. CI. Bernard supposed that this ferment was special to the
liver like the glucogenic matter. He even succeeded in obtaining it in an
isolated state, though he gives no account of it. But he soon found that the
blood generally possessed this fermentative power, and transformed the sugar
making matter with very great energy into sugar. The ferment of the liver
is, then, evidently derived from the blood circulating in it.

These highly interesting researches of M. CI. Bernard, establish in appa-
rently the clearest manner, that in the normal state, the liver, by its nutritive
or proper organic actions, creates an amyloid substance, analogous to, if not
identical with, vegetable starch; and that some element of the blood, acting
as a ferment, transforms it into glucose or hepatic sugar with a rapidity nearly
as great as its formation.

Si. E. Pelouze took up the chemical history of the glucogenic substance
of the liver where it was left by M. Bernard, and has completed it. He has
proved the correctness of Professor Jones' idea, that gun-cotton might be
made from the liver. "I sought," he observes, "whether the (hepatic) glu-
cogenic matter, under the influence of fuming nitric acid could be transformed
into xyloidine like starch." The results were identical. "The xyloidine
obtained was very combustible and detonated with flame when heated to a
temperature of 180°."

Under the influence of diluted nitric acid, it was converted into oxalic
acid.

Analysis furnished the following result : —

Carbon . 39.8

Hydrogen 6.1

Oxygen 54.1

100.

corresponding to the formula

The formula of vegetable starch, treated in the same manner as hepatic

starch, is

1 Comptes Rendus, 29 Juin, 1857, p. 1321.

1857.]

Original Communications.

551

The identity of the two is fairly established, and the function of the liver
is not glucogenic, but amylogenic.

Assuming as correct the discovery of M. CI. Bernard, that starch and not
sugar, is the immediate product of the liver, the mechanism or process of the
anatomical modification of the liver in yellow fever, becomes apparent. The
yellow fever poison introduced into the blood, vitiates its vital, anatomical,
chemical and physical characters, properties, relations and modes of action in
the organism. All its functions are at first perverted, and ultimately, if the
dose be powerful, are suspended or destroyed. The blood ceases to be normal.
This profound change of the circulating fluid, the effect of a large dose of the
poison, is invariably fatal.

The fermentative power of the blood being more or less impaired, and
finally destroyed, the transformation of the amyloid substance of the liver into
sugar, is imperfect, or is not accomplished; the secretion of bile is at the
same time arrested, and in consequence the amyloid element of the liver as-
sumes an undue proportion in its structural composition.

The peculiar character of the liver in yellow fever was first distinctly an-
nounced by M. Louis, as observed by him at Gibraltar. It has been usually
supposed to be a form of fatty degeneration, though no regular and sustained
chemical analysis, that I am aware of, ever demonstrated the fact

The theoretical deduction from Bernard's physiological facts, would demon-
strate it to be an amyloid degeneration ; and this theoretical conclusion is
borne out by Professor Jones' observations on the yellow fever liver. What
gives great weight to his facts is, that his results were anterior to Bernard's
discovery of the amylogenetie function of the liver. He was under no pre-
conception that often deludes observation. On the contrary, he appears to
have been staggered by the unexpected discovery he had made, and post-
poned announcing the fact until he had fortified his results with additional
observations.

Professor Jones found unequivocal evidences of cellulose (amyloid sub-
stance) in a liver of a patient who died of bilious remittent. This is to be
expected, for if the production of an amyloid matter is a normal function of
the liver, it will be found in most cases of acute disease, in a certain pro-
portion.

It may be questioned whether Louis' yellow fever liver will prove to be an
invariable attendant on yellow fever. In the epidemic of 1820, I made a
post-mortem examination of a man, who died in less than 24 hours from the
attack, in consequence of violent cerebral symptoms, attended with convul-
sions. The stomach was filled with black vomit. The liver was of a deep
purple hue, gorged with fluid blood that flowed in copious streams from in-
cisions, and was collected in several cups for the purpose of examination. The
characters of yellow fever liver are generally developed in proportion to the
duration of the case.

In a letter of date August 13th, Professor Jones informs me he had had
an opportunity of examining a true fatty liver, and could detect no signs of
cellulose (amyloid matter) in it.

The preceding facts authorize the following conclusions: —

1. That the liver is a generator or creator of amylum or starch (Bernard
and Pelouze).

2. That the hepatic starch is transformed in the liver by a ferment existing
in the blood into dextrin and glucose, in the same manner as starch in vege-
tables is transformed by diastase into dextrin and glucose (Bernard).

3. That in yellow fever from the alteration of the blood this transformation

552

American Intelligence.

[Oct.

does not occur, and that an amyloid substance, probably cellulose, exists in
the liver to a large amount (Jones).

4. That this anatomical alteration of the liver is not special to or pathog-
nomonic of yellow fever, but occurs in other fevers (Jones), and in some
chronic forms of disease (Virchow, Bennett, and Carter of Ed.).

5. That this pathological alteration of the liver has no direct influence on
the rapid course of yellow fever and its great fatality, which are due solely
to the immediate power of a specific poison corrupting the blood and extin-
guishing the vital forces.

Vaccine Virus administered Internally for the Cure of Smallpox. — [We
have been favoured with the following communication, and cheerfully lay it
before the profession. Though the new remedy may be regarded with some
suspicion, it is only by trial that its power can be positively determined.]

Department of State, Washington, July 28, 1857.
To Doctor Isaac Hays, Editor of the American Journal of Med. Science, Phila.

Sir : I inclose herewith a copy of a communication recently transmitted to
this Department by N. 0. Cornwall, Esq., Consul of the United States at Rio
Grande do Sul, in Brazil, in relation to the alleged efficacy of the vaccine virus
administered internally for the cure of smallpox.

It does not fall within the province of this department to express any opinion
as to the value of the discovery claimed by Doctor Landell. I have thought it
due, however, to the cause of humanity, and to the spirit of philosophic inves-
tigation which characterizes the science of medicine, to place Doctor LandelPs
claims before the profession, in his own words, in order that they may undergo
that ordeal which will be the true test of their value ; and that, also, by their
confirmation, the name of the discoverer may be written among the benefactors
of the human family, imperishable as that of Jenner, and forever associated
with it.

It may be proper to mention that an extract from Dr. LandelPs memoir has
been communicated to the Union newspaper of this city. Your valuable jour-
nal has been selected as the representative of its class, in order to bring the
subject directly to the attention of the profession. It would be a matter of in-
finite satisfaction to know that the anticipated results of Doctor Landell's mode
of treatment have been verified. I am, sir,

Your obedient servant,

LEW. CASS.

Vaccine given Inwardly for the Cure of Smallpox. By R. Landell,
M. D. — In the months of August and September, in the year 1837, in this
city, a terrible epidemic pestilence of the smallpox cut off maDy valuable
lives. I also had to lament the loss of a very fine boy, who fell a victim to
this contagious epidemy. The sorrowful remembrance of this event induced
me, when the disease broke out again in the year 1842, to put in practice an
idea which I had since that unlucky year, 1837. My opinion was that, by
giving inwardly vaccine lymph to those sick of the smallpox, it would be
rendered much milder. I also requested my son, John Landell, now Doctor
in Medicine, to make some trials under my directions of vaccine internally,
in various of my patients labouring under smallpox ; the results were the
most satisfactory, because they became benign and distinct. So, then, count-
ing from this year, 1842, till the year 1854, and again until these last months
of the present year, I have verified the virtue and advantage which are to be
derived from the internal use of vaccine for the cure of variola or smallpox.
Based on these principles, L perform a humane duty in making known to the
public this system, which I have adopted for the cure of smallpox.

1857.]

Original Communications.

553

Dissolve the vaccine that is contained on a pair of plates or a capillary
tube, which is about four or six drops of vaccine lymph, in four or six ounces
of cold water, and give to the patient a tablespoonful every two or three
hours.

The favourable result of this exhibition is that it mitigates the symptoms,
modifies the species, and cures the smallpox.

I recognize that, as vaccine applied externally prevents the smallpox, so
also being taken inwardly, in the manner above indicated, it cures quickly
and efficaciously the smallpox in all its stages.

Under its use, the fever, the delirium, the hoarseness, diarrhoea, pneumonia,
cerebral congestion, and finally the secondary fever, disappear.

Beginning the treatment on the second or third day of the eruption, the
smallpox becomes as varicella or varioloid, although the epiderm is thickened
and in a state of congestion, in five days dry without suppuration.

Applying the same treatment on the fourth or fifth day of the eruption,
the smallpox become as if they were the true vaccine, fill and dry in the space
of ten days, with suppuration.

Considering, then, that the vesicles and pustules ought to be opened for
two or three times, always when they contain any liquid, and beginning the
third day to prevent the secondary fever. I have had since 1842 more than
thirty cases, and in fourteen paid particular attention ; they were three severe
confluent cases, and eleven less severe, although distinct.

Since I had recourse to this treatment I have not lost a single patient of
the smallpox. At my request, some of my colleagues are using this system,
and they, as well as I, have reaped the most flattering results. These effects
are superior to my expectation, and even to my comprehension ; in fact, the
vaccine neutralizes the variolic virus, or one morbid action destroys the effects
of another. By this treatment I have seen disappear the fever, delirium,
hoarseness, diarrhoea, pneumonia, cerebral congestion, and the secondary
fever.

It may be mentioned here that the use of emollient clysters or castor oil
internally, to keep the bowels loose, and in children calomel, is very neces-
sary ; as also gargles of nitrate of silver and chloruret of lime. And after
the fifth day, give baths of warm water, with a little chloruret of lime or
chloruret of soda, or sponge the body.

Also have given vaccine inwardly as a therapeutic remedy in hooping-
cough, and with benefit ; in some cases the hoop or convulsion cough disap-
peared in ten hours, remaining only a simple cough, which extinguishes in
four or twelve days.

For my part, I render thanks to God for giving me the knowledge of this
method to cure by so admirable a mode a disease so Satanic as the smallpox.
Would to God that this small contingent of my poor intellect serve to as-
suage the sufferings of those labouring under this cruel epidemy !

Porte Alegre [Brazil], March 12, 1857.

Case of Fracture connecting with Frontal Sinus and Exposure of Frontal
Nerve. The Nerve divided. By W. Lehman Wells, M. D., Resident in
Pennsylvania Hospital.

John Funk, aged 44, teamster, a resident of Holmesburg, was admitted
Monday, January 12th, 1857, at 5 A. M., with compound fracture of the
frontal bone, which had occurred twelve hours previously. He had been
employed in a livery stable at Holmesburg, and while in a stooping posture

554

American Intelligence.

[Oct.

was kicked over the right eye by a horse, and thus rendered insensible for
some time.

There was a wound about three inches long just below the eyebrow, which
extended also a little on each side. This had been sewed up at first, the
man said, by a surgeon, but afterwards opened, with the exception of a stitch
near each corner, on account of hemorrhage. The neighbouring parts were
swelled very much, and there was ecchymosis around both eyes, which on the
right side extended under the conjunctiva, and was very great The bleed-
ing had not yet altogether stopped, and must have been considerable from
the appearance of the bandage and his clothes. It, however, soon ceased
spontaneously upon removing the bandage, turning out the clot, and sponging
with cold water.

There had been also bleeding from the nose, which was accounted for by a
depressed fracture of the orbital plate of the frontal bone. This fracture was
just internal to the frontal nerve, which was exposed in one or two lines of
its length. There was very great pain both in the eye and in the forehead.

Fearing that the danger of inflammation from the injury to the eye would
be increased by reflex action from the exposure and laceration of the frontal
nerve, I divided it as closely to the proximal extremity as possible, causing
very great pain for a moment, and then immediate relief from all the pain he
had previously had in the eye, and nearly all on the forehead. The edges of
the wound were brought together by the interrupted suture and adhesive
plaster, and lint wet with cold water applied. He took sennae fol. 3j> mag-
nesise sulph. 3ij, which operated twice.

In the afternoon, his pulse being 90, skin warm, and tongue furred, he
was ordered liq. potassae citratis f^ss every three hours. This was stopped
the next day, as all symptoms of fever had subsided.

The wound healed up rapidly, except in a small place, where a sinus re-
mained with a piece of dead bone at the bottom. Before this became loose,
however, he went away, at his own repeated request, on the 2d of February,
having remained twenty-one days. His sight, after the first day or two, was
perfect on both sides.

Extrusion of an Ovum at the Fifth Month of Utero Gestation with the
Membranes entire. By J. F. Grant, M. D., of Bradshaw, Tenn. — I was
called to Mrs. P. with hemorrhage, together with other symptoms of abortion,
consequent upon an injury which she had sustained. She was five months
gone in pregnancy. Shortly after my arrival, a foetus was extruded with the
placenta and membranes entire. The circulation went on beautifully for thirty
minutes, when I severed the cord, which was still pulsating regular and with
good volume. I think it is probable that the circulation might have been
kept up for several hours and perhaps days. This and other similar cases
that have occurred certainly go very far to prove the independent existence
of the foetus in utero, bearing the same relation as the chick in ovo does to
the parent bird. It was a case of twins, but the latter was expelled after the
rupture of the membranes.

P. S. The child died immediately after the cord was cut.

Indian Corn in Intermittent Fever. By D. B. Phillips, M. D., Passed
Assistant Surgeon U. S. N. — I beg leave, through the medium of your
journal, to call attention to the efficacy of Indian corn (maize) as a specific of
some value in intermittent fever.

1857.]

Original Communications.

555

Having been called to a case of this fever in the country, and having no
medicine convenient, I determined to make trial of a negro remedy, maize.
My patient had been suffering with the quotidian type of intermittent fever
several days before I saw him. On Wednesday, at 11 A. M., when I was
first called to see him, he was in the hot stage, and so high was his fever that
he was occasionally delirious in a slight degree. I commenced by giving him
a large tablespoonful of uncooked and unsifted corn meal, mixed in a glass of
cold water, and directed him to take the same quantity every two hours. At
night I gave him six grains of calomel (the only medicine I had). On the
following day, Thursday, the same treatment was continued (with exception
of the calomel, which was given but once), and the paroxysm, which was
much milder than on Wednesday, was postponed until 1 P. M. I continued
the meal and water for two days more, during which there was no return of
the disease. I then discontinued it altogether, and the patient has been well
and hearty ever since.

Of the modus operandi of maize I know and can say nothing. My patient
remarked that it relieved his thirst in the hot stage more effectually than
anything he had ever used before, and the fever was more rapidly subdued
by it. I trust that future experience may confirm the virtues and value of
this simple remedy.

"Washington, D. C, July 15, 1857.

Account of a Case in which both Ovaries were extirpated by Dr. H. A.
Potter. By James H. Tinkham, M. D., of Geneva, N. Y.

Inclosed is an account of an operation in which both ovaries were success-
fully removed by Dr. H. A. Potter, of this place, and also a brief history of
the case. As it is an operation of the first magnitude, and one which pre-
sents some points which may be of importance when the subject of ovario-
tomy is considered, I have no doubt it will prove interesting to your readers.

The patient was a married lady, twenty-five years of age. She first discovered
a small tumour in abdomen about two years ago \ from that time to the present
it has increased gradually, but within the last two months more rapidly than
before. During this time her general health has been good, she has been
under no medical treatment, nor has the tumour been tapped. When she
consulted Dr. Potter the tumour was of immense size, distending the walls of
the abdomen from the pubis to the sternum. He decided, from its appear-
ance and previous history, that it was an enlarged ovarium, and ordered it to
be tapped. This was done on the same day, and nine pounds of a dark
coloured, pasty-looking fluid drawn off. Having now ascertained beyond a
doubt the character of the tumour, he recommended an immediate operation
as affording the only chance for recovery. This, having been decided on by
the patient and friends, was performed in the following manner by Dr. Pot-
ter, assisted by Drs. Peck, Bolton, Graves, Whitbeck, Hawley, Frost, and
myself. The room was heated to a temperature of about 80°, the patient
placed on a table of convenient height in the centre of the room, and chloro-
form administered. An incision was then made extending from the umbili-
cus to the symphysis pubis along the linea alba, the tissues were carefully
dissected until the peritoneum was reached, some small arteries were ligated,
the blood sponged away, and the peritoneum opened, when the tumour pre-
sented itself. It was slightly adherent to the omentum, but was easily sepa-
rated from it by the fingers and handle of the scalpel. A trocar was intro-
duced into the lower part of the tumour, and a large quantity of fluid nearly

556

American Intelligence.

[Oct.

the colour of water drawn off. As this did not empty the tumour, it was
evident there were two cavities. The trocar being introduced into the other
cavity, about the same amount of fluid was evacuated as before, but of a
darker colour and thicker. As the size of the tumour was still such as to
prevent its being lifted from the abdomen, the incision was extended above
the umbilicus about two inches; the tumour was then easily lifted out,
and proved to be the right ovarium, the broad ligament of the uterus con-
stituting its pedicle. This pedicle was cut close by the tumour, was split
longitudinally into three parts, and a strong ligature applied firmly to each
part. This tumour with its contents weighed twenty-two pounds. The left
ovarium was then examined. It was about the size of a large hen's egg, and
in a diseased condition ; it was consequently removed, and a single ligature
applied to its pedicle. The protruded intestines were placed back with linen
cloths wet in warm water. The lips of the wound were brought together and
retained by the common interrupted suture and adhesive straps. The cut
extremity of the pedicle was placed as near as possible to the lowest part of
the wound, and retained in place by three ligatures, which were fastened
together and brought out between the lowest suture and the lower angle of
the incision. A strip of lint and a thick cotton compress were laid on the
wound, and the corset bandage applied — a bandage well adapted to prevent
danger from action of abdominal muscles, and one which could be easily
opened. The patient was left in charge of Dr. Whitbeck, attending physi-
cian, from whose report of the after-treatment I extract the following
portions.

April 23^. Four hours after operation, patient felt considerable pain in
lower part of abdomen; pulse from 110 to 115. Catheter introduced, and
a quantity of urine removed. Prescribed sul. morphia | gr.

2I/7&. Pulse 125 ; tongue dry ; pain in abdomen. Evacuated bladder by
means of catheter. Gave small doses of veratrum viride at intervals of four
hours, which reduced frequency of pulse from 125 to 98, at or near which
point it has remained ever since.

26^. Patient seized with vomiting in morning. Gave a teaspoonful of
brandy in a little water, and afterwards small doses of sul. morphia. Bad
symptoms soon subsided. Also gave submurias hyd. ij grains every two
hours, until ten grains were taken, followed by castor oil and an enema. A
free evacuation of the bowels took place during the night.

The rest of the treatment consisted in an occasional dose cf morphia and
of veratrum viride. The ligatures were all removed by the 25th of May,
and the patient discharged.

Ca.se of Herpes Preputialis. By H. T. Goldsborough, M. D., of Easton,
Md. — In looking over the American Journal for July, 1854, 1 find a case of
" herpes preputialis," which had returned after being cured five times conse-
cutively.

A case of precisely similar character was cured by me in the following
manner : The disease occurred in a young and healthy man, without previous
exposure. The herpes yielded readily to the usual astringent remedies, but
appeared to lie dormant in the glands and prepuce, and recurred upon disor-
der of the stomach, or tne presence of fever in the system. Attributing,
finally, the recurrence to the heat and secretion of the glans (cleanliness being
all the time strictly enjoined and observed), I directed that the prepuce
should be kept retracted behind the " corona." This was attended at first

1857.]

Domestic Summary.

557

•with some inconvenience, but by perseverance the prepuce adapted itself to
the retracted position, the secretion was diminished almost entirely, and I am
glad to say that the herpes has not since returned.

I have been led to relate this case simply because I have not seen the same
mode of treatment adopted elsewhere.

July 12, 1857.

DOMESTIC SUMMARY.

Dislocation of the Processes of the Cervical Vertebrae. — Dr. E. R. Maxson re-
ports {Buffalo. Med. Journ., Jan. 1857) an interesting case of this in a girl nine
years of age, who, when playing, after a sudden turn of the face toward the
left shoulder, experienced pain in the back of the neck, became faint and was
unable to turn her head back to its natural position. She continued much in
this condition until late in the evening of the second day, when in attempting
to move her in bed the face, by accident, was turned a little more toward the
left shoulder, as was supposed, when she was severely convulsed for a consi-
derable time: after which she became very faint, and could not bear to be
raised up much in bed. At this time, forty hours after the accident, Dr. M.
was called to the patient. He found her in bed with her face turned to her left
shoulder, and without the ability to move or turn the head. The eyes were
apparently fixed, and the countenance unnatural. On passing his hand along
the spinous processes of the cervical vertebrae, Dr. M. distinctly felt at the fifth
and sixth vertebras an irregularity of the spinous process of the fifth or sixth
vertebras appearing to the right of the one below. Dr. M. feeling satisfied that
there was a dislocation grasped the head with both hands and proceeded ac-
cording to Desault's method, only he first carried or turned the face very gently
a little further toward the left shoulder, to, if possible, disengage the process ;
then lifting or extending the head, he turned the face very gently toward the
right shoulder, when the difficulty was at once overcome, and she exclaimed,
'1 can move my eyes/

" Her countenance soon acquired a more natural appearance ; the faintness
passed off ; she rested quietly through the night ; had no return of the difficulty,
and needed only an emollient anodyne to soothe the irritation and slight swell-
ing which remained at the point of injury.

Change of Colour in a Negro. — The following remarkable example of this is
related by Dr. W. L. Sutton in his Report relating to the Registry and Returns
of Births, Marriages, and Deaths in the State of Kentucky for 1855. " This
year, 1855, there was born, at Mr. J. Smith's, in the county of Fayette, a lusus
naturce, which is very rarely found. In May, a female child was born, entirely
black, and of black parents. When I saw it, in August, a large portion of the
hands and forearms was of the appearance of the most delicate skin of a white
child of the same age. There was little gradation of colour, but the change
was abrupt. On other parts of the body were spots of a smaller size, and of
the same colour. Since that time considerable changes have occurred. The
same portions have been alternately white and black. I visited the child a few
days ago, to see its present condition. The child was represented to have en-
joyed good health, and at first sight it might not have been remarked as at all
different from many negro children. The skin is generally black, of a rather
dry aspect, as if she was not in very good health. There are no extensive co-
loured spots, but she is sprinkled all over the surface with spots from the size
of a millet-seed to that of a grain of Indian corn, of irregular shape, but gene-
rally inclined to round or oval. These spots have nothing of the delicacy of
appearance which characterized the white portions soon after birth; but were
of a dull ashy colour. There is nothing in the colour or condition of the hair
or eyes to distinguish her from other negro children.

558

A merica n In telligen ce.

[Oct.

" In the July, 1846, number of the American Journal of Medical Sciences, is
an account of a somewhat similar change of colour observed in a native of
Africa, by Thos. J. Savage, M. D. In that case the change had been preceded
by serious indisposition. The health before and after that time was reported
to have been good. The colour of the feet and ankles, in the plate furnished
by Dr. Savage, gives a very good idea of the colour of the hands and forearms
of the child above mentioned, but there was more delicacy of colour in the
child ; but at no time the same extent of surface undergoing change of colour ;
nor was there any desquamation of the cuticle. Unlike Dr. S.'s case, too, the
parts exposed, and those covered are, at present at least, equally spotted."

Case of Death by Syncope from Plugging the Pulmonary Artery. —The fol-
lowing interesting example of this is recorded by Dr. 0. M. Allaben, in the
Transactions of the Medical Society of the State of New York, for 1857.

The patient, a male, 33 years of age, was attacked on the 4th of April, 1856,
with inflammation of the lungs, for which, on the 8th, he was bled until complete
syncope occurred, which took place much sooner than was anticipated, and
before twelve ounces of blood were lost. Great relief followed the bleeding.
He was directed a dose of calomel and jalap, to be followed by antimonial ex-
pectorants, and a blister to the chest. On the next day the urgency of the
symptoms had considerably abated, but the patient still complained of some
pain in the left breast, particularly over the region of the heart. The pulse
was hard, strong and frequent. The patient was again bled with the same
result as before, early fainting and abatement of symptoms. The other reme-
dies continued.

The case progressed favourably until the 25th of April, when Dr. A. called
to take leave of the patient. He found him free from symptoms of pulmonary
disease, with a good appetite, and able to walk about the room. The pulse
was, however, more active than the condition of the patient would seem to
indicate. The patient complained 'of a sore spot at his heart.' From this,
however, nothing serious was apprehended.

In the evening he proposed to join the family at tea. To Dr. A.'s objecting
to his making so much exertion, he replied that he had dined with the family and
would take tea with them. Accordingly, with the assistance of his wife he
dressed himself, walked into the supper room and sat down at the table.
Before commencing the meal he fainted. Dr. A. immediately inclined his
chair backwards, elevating his feet above his head, and dashed cold water into
his face. In about a minute afterwards he gasped for breath but exhibited no
further sign of returning animation. A feeble pulsation was perceptible at
the wrist. At intervals of about one minute each, the patient gave two suc-
sessive gasps and expired. After the pulse had ceased at the wrist, and for
some minutes subsequent to the last gasp, the action of the heart could be dis-
tinctly felt by the hand placed upon the chest. The body was examined forty-
eight hours after death.

"Both lobes of the lungs presented a dark, uneven, mottled appearance, and
had evidently been the seat of high inflammatory action. They had a spongy
crepitous feel, and air bubbles escaped when portions were pressed between the
thumb and finger, but no blood. The stomach, liver and intestines appeared
healthy. The right side of the heart, including the vena cava, was found enor-
mously distended with dark, grumous, coagulated blood. Upon breaking down
the clot with the finger a reddish, organized, fleshy substance was detected, pro-
truding into the coagulum from the mouth of the pulmonary artery, into which it
had become firmly impacted, plugging it up like the cork of a bottle, and com-
pletely cutting off all communication between the heart and lungs. It was
nearly as thick as the end of the little finger, and about an inch in length. The left
cavities of the heart were of course found empty. The brain was not examined.
The right ventricle of the heart had an unusually smooth and reddish appear-
ance, and upon further examination there were found attached to its parietes,
and filling up the sulci formed by the columni carnae, two other organized
deposits, similar to that taken from the pulmonary artery. One about the size
of a small bean, and the other as large as that plugging the artery. Both had

1857.]

Domestic Summary.

559

a ragged, irregular form, and were attached to the heart by a vascular union,
which easily yielded to a moderate traction, by which they were removed.
These formations were preserved in alcohol, and after ten months present
nearly the same appearance as when they were removed.

" The cause was now apparent. The organized substance found in the pul-
monary artery, had been formed in the ventricular cavity, like those there
found attached. By the constant action of the heart it had become detached,
and by the very next pulsation was carried into the pulmonary artery, thereby
cutting off the supply of blood to the lungs, left side of the heart, and brain,
and causing immediate death by syncope. Whether these extraneous forma-
tions were the result of previous disease, or were produced by the same cause
that caused the pneumonia, can never be known ; but that inflammatory action
of the parietes of the right ventricle had existed, admits of very little doubt ;
and that it had resulted in depositions of fibrous or coagulable lymph, seems
equally certain. These had become organized by the extension into their sub-
stance of the excited vessels of the living surface, and they had become morbid
growths. The unusual activity of the circulatory system during the pulmonary
disease here finds its prompter ; and the ' sore spot at the heart' points to the
same exciting cause; while the great susceptibility to syncope may have been
owing to the morbid irritability of the walls of the ventricle, and a consequent
increased disposition to respond to the loss of its accustomed stimulus. The
severity of the pulmonary symptoms for a while diverted attention from the
cardiac difficulty ; although my fears were frequently excited and as often ex-
pressed, that the heart was participating in the abnormal changes that were
taking place."

Delirium Tremens following an attack of Pneumonia. — Dr. J. J. Summerville
reports ( Transactions of the Eighth Annual Meeting of the Medical Society of
North Carolina) the following case : —

"J. C, a dealer in tobacco, from Patrick County, Ya., aged 35 years, was
attacked by pneumonia, May 5, 1854. This case presents nothing interesting
in itself ; and, but for the disease which made its appearance at the decline of
the inflammation of the lungs, would not be mentioned as deserving particular
attention. The treatment was that which I usually adopt in plain, uncompli-
cated cases of pneumonia, viz., tartar emetic in doses barely tolerated by the
stomach during the day, with calomel and Dover's powder at night, vs.,
cups, etc.

"On the sixth day there were all the indications of approaching convalescence.
On the seventh I found him up, and he stated to me that he was quite well, but
that some one had been all the morning trying to shoot him through the win-
dow. The people with whom he was living told me that he had been walking
about the yard that morning, and had seemed much annoyed and disgusted by
the many loathsome objects which he fancied he saw on every side ; nor would
he be persuaded that these objects existed merely in his imagination.

"Here was a plain case of delirium tremens, and of course I made inquiry
as to his habits of life. To my great surprise, I found that he was strictly tem-
perate, seldom tasting spirits, and had never in his life been intoxicated. The
usual treatment was instituted — brandy and opiates — until sleep was obtained.
He continued restless and excited, with occasional paroxysms of terror, for
about three days, when sleep overpowered him, and he recovered by degrees
his right mind. Nothing unusual happened during his convalescence. He was
much prostrated at first, but soon regained health and strength."

Poisoning from an overdose of the Tincture of Cantharides. — Dr. H. Kelly
reports (Transactions of the Eighth Meeting of the Medical Society of North
Carolina) the following case of this : —

"The subject was a mulatto child, two years and nine months old. Its mo-
ther, by direction of a physician, procured an ounce of tincture of cantharides
for her own case. An elder brother of the subject, in the absence of the mother,
got the phial, and persuaded the child to swallow a drachm — about two-thirds
of the contents of the phial. In a short time the child became very sick and

560

American Intelligence.

[Oct.

restless, with frequent efforts to vomit. Two hours and a half afterwards almost
incessant vomiting set in, and continued for some two hours, when it was dis-
covered that the child had taken the poison. On my arrival, five hours after
the accident, it threw up what the parents supposed to be a worm. This, how-
ever, I discovered to be the mucous membrane of the oesophagus entire, which
I have preserved in alcohol. It was 4£ inches in length. I ordered a table-
spoonful of flaxseed-tea to be given every 15 minutes, which was immediately
rejected. Slippery elm was given, with the same result. At 8 o'clock P. M. I
gave equal quantities of water and sweet milk, in the same dose, at intervals of
20 minutes. This was retained somewhat longer. At 1 o'clock A. M. it remained
from three to five minutes before rejection. 4 o'clock A. M., no urine or feces
had been discharged. An injection of flaxseed-tea was administered, and re-
peated within an hour, without bringing away any fecal matter. An injection
of olive oil and molasses, a drachm of each, with four ounces of Castile soap-
suds, was then given, by which a copious discharge of fecal matter was pro-
cured ; a small quantity of urine was also passed, highly coloured, without any
trace of blood. 2 o'clock P. M., patient better. Continue milk and water;
every third dose flaxseed-tea or slippery elm. 10 o'clock P. M., patient retains
drink for 10 to 15 minutes. Third day, 8 A. M., patient improving; same
treatment continued; drink every hour; occasionally short naps of sleep ob-
tained; passed a small quantity of urine, still high coloured. After injection,
fecal discharges, without any appearance of blood. Drinks retained 15 to 20
minutes. 8 o'clock P. M., patient improving; drinks given alternately with
rice-water; retained. Fourth day, 6 o^clock A. M., patient slept more during
night; the fever, which has been high from beginning, is abating ; emesis not
more than once every two hours. 5 P. M., patient vomited but once since last
visit; is clear of fever; urine assuming a natural appearance, but small in
quantity ; an injection was administered, which had the desired effect. From
this time convalescence took place rapidly. In a week the patient was entirely
recovered."

Extraordinary Obesity. — We find in the Nashville Journ. of Med. and Surg.,
Aug., 1857, the following particulars respecting Miles Darden, whose size may
appear almost fabulous, but the facts seem well vouched for.

" Mr. Darden was born in North Carolina in 1798, and died at his residence
in Henderson County, Tennessee, January 23, 1857. He was seven feet six
inches high. In 1845 he weighed eight hundred and seventy-one pounds, and
at his death a fraction over one thousand pounds, and was unquestionably the
largest man in the world, and since ' those days' in which there were giants,
the largest man the world has produced. Up to 1853 ' he was quite active
and lively, and laboured,' after which, his fat increasing, he was compelled to
stay at home or be hauled about in a two-horse wagon. It required thirteen
and a half yards of flax cloth a yard wide to make him a coat. It required
sixteen yards of cambric for his shroud, and twenty-four yards of black velvet
to cover his coffin."

Exsection of the Head of the Humerus. — This operation was performed in
June last by Prof. Geo. C. Blackman, in the case of a lad 5 years of age,
admitted into the Commercial Hospital, with caries of the head and upper ex-
tremity of the humerus. The wound healed without any untoward symptom,
and the lad is now in good health and has a pretty good use of the limb.
Western Lancet, Aug., 1857.

Gelseminum Sempervirens in Gonorrhoea. — Dr. John Douglas, of Chester
District, S. C, states [Charleston Med. Journ., July, 1857), that " about thirty
years ago, I was called on, in my office, by a young man who had been suffer-
ing several months with improperly treated gonorrhoea. One of my pupils
begged me to give the case to him, observing that he could cure the most
obstinate case in a few days with the root of yellow jessamine. A small
handful of the root was put into a common junk bottle of whiskey, and the
patient ordered, in a day or two, to take a tablespoonful of this tincture night

1857.]

Domestic Summary.

561

and morning. He took but a few doses before he became much alarmed, and
called on me, stating that the medicine had destroyed his vision. The symp-
toms he described correspond precisely with those mentioned by Dr. M. Every
symptom of gonorrhoea had disappeared, and the cure was permanent. Since
that time I have treated many cases of the same character in a similar manner
with uniform and speedy success."

My experience with the medicine is not sufficient to determine whether it is
absolutely necessary that the patient should be fully narcotized, but such was
the condition in every case which I treated. I have no doubt but a more pro-
tracted use in smaller doses would answer the purpose.

Preservation of Vaccine Matter by Solution in Glycerine. — The Chicago corre-
spondent of the Peninsular Journal of Medicine, states that Dr. Andrews, of
Chicago, has made some experiments in the preservation of vaccine virus by
solution in glycerine, using the solution instead of the solid matter for vaccina-
tion.

In Dr. Andrews' experiment, the vaccine matter was kept in solution two or
three months of warm weather, at the end of which time seven cases were
vaccinated with it, without a single failure. The scab broken into three or
four pieces is thrown into a little glycerine, and occasionally shaken. It will
slowly dissolve without further care. Dr. Johnson has repeated Dr. Andrews'
experiments with success.

Woman with four Mammce. — An example of this occurred lately in the Charity
Hospital. The supplementary nipples were situated about two inches below
the others. The patient had had seven children and was accustomed to suckle
from three of the nipples. All furnished milk equally well, but the right sup-
plementary nipple was small. — N. 0. Med. News and Hosp. Gazette, Sept. 1857.

[M. Roberts (see No. for Aug., 1828, p. 412), records two cases, a mother
and daughter, in which each had three mammae. In one the third mamma
was in the groin and served to suckle several children.]

Philadelphia Hospital, Blockley. — At a meeting of the Guardians of the Poor,
held on the 8th of June last, Dr. James McClintock was elected Chief Resident
Physician to this Institution. This appointment has been regarded by the
profession of Philadelphia as a gross insult to them, and has been indignantly
denounced both by the College of Physicians of Philadelphia and by the
Philadelphia County Medical Society.

Immediately after the appointment of Dr. McClintock, all but one of the
Resident Physicians of the Blockley Hospital, and all the members of the con-
sulting medical, surgical and obstetrical staff resigned.

Of Dr. McClintock, we are unable to speak from personal acquaintance ; but
the following episode in his history as it is related by one who claims "long-
time friendship"1 with him, may be deemed authentic, and may serve to
enlighten the reader as to his career: —

"It is now only three or four years since Dr. James McClintock, of Phila-
delphia, in an evil hour, consented, for a consideration of some $5,000, to fur-
nish a series of recipes for ' Family Medicines/ and to allow his name and
titles to accompany their announcement, in the usual style of nostrum venders,
he and his heirs retaining an interest in the sales. The moneyed parties to
this new phase of quackery were understood to be Thos. McElrath, Esq., of
the N. Y. Tribune, and Wm. E. Burton, Esq., of the theatre, both of whom
entered into this speculation with as high hopes as they ever made investments
in any other 4 fancy stocks and by dint of columns of advertisements, and
editorial puffs from all the presses known to be in the market for hire, they
rivalled Brandreth, Moffet, Jayne, Ayres, and even Hunter ! in their advertis-
ing patronage to corruptible newspapers.

1 Dr. D. Meredith Reese.

No. LXVIIL— Oct. 1857. 37

562

American Intelligence.

[Oct. 1857.]

* * * « The bubble soon burst, and the 'Family Medicines' -were a drug
in the market, with no purchasers, either by wholesale or retail, but not until,
it is said, some seventy thousand dollars had been sunk in the wild experiment.
Meanwhile Dr. McC. was displaced from the American Medical Association for
his offence against the code of ethics, and hence suffered a worse than pecu-
niary loss."

After announcing Dr. McC.'s appointment, his friend, from whom we quote,
adds : " Simultaneously he has renounced and repudiated all association with,
or interest in, the business of nostrum vending, and has published, in the
Philadelphia Med. and Surg. Journal, all his famous celebrated recipes in detail.
pro bono publico." — American Medical Gazette, July, 1857.

"We have in common, we believe, with every right minded physician, felt
indignant at the appointment of Dr. McClintock, but we cannot say that it has
either surprised or mortified us. It is one of the evils resulting from our
social system to throw the governing power of many of our eleemosynary in-
stitutions, in which philanthropy and science should be the sole ruling influ-
ences, into the hands of mere politicians. Such are most of the managers of
our Blockley Hospital. Elected solely on political grounds, they are incapable
of any liberal or genuine philanthropic sentiments, and are utterly unable to
appreciate the high and disinterested principles which govern the medical pro-
fession. That such persons should have been induced to elect to a high and
responsible medical position an individual whose name had been stricken from
the roll of membership of the American Medical Association for conduct con-
sidered by that illustrious body eminently derogatory to professional character,
need not therefore excite surprise. Connected, however, with this subject is
a circumstance which, we must confess to have deeply mortified us. It is that
a member of the profession, one unhappily, at the last meeting of this same
American Medical Association, elevated to the honourable office of one of its
Vice-Presidents, should have exerted his influence to promote the election of
Dr. McClintock, and even have made use of that title to give force to his recom-
mendation.

That we may do full justice to Dr. Reese, we subjoin his attempted justifi-
cation:—

" Dr. James McClintock has been appointed, by the Guardians of the Poor
of Philadelphia, Resident Physician-in-chief at the Blockley Hospital of that
city. We are sorry to learn that the Assistant Physicians have resigned in a
body, alleging as a reason the late exclusion of Dr. McC. from the American
Medical Association, for his amalgamation with nostrum venders. They seem
oblivious to the fact that this appointment was not made, nor even recom-
mended by anybody, until after he had made a public recantation of the error
of his life, and a disclaimer of all participation in the medical heresy for
which he had been censured by his peers and condemned by the profession.
But for this assurance, our signature advising his appointment could never
have been obtained, much less would we have testified to his qualifications as
a physician and a surgeon, fitting him for the place. But learning by authority
that he had made all the atonement in his power for his violation of the Code
of Ethics, and being assured that he would 1 go and sin no more/ our resent-
ment for his temporary apostasy ceased, and the recollection of what he has
been as a medical teacher and practitioner, revived the long-time friendship
which his error had broken, and we could not withhold our forgiveness of the
repentant wanderer, consistent with our reverence for the ' higher law/ " —
American Medical Gazette, July 1857.

Comment on this specimen of sophistry and cant is wholly unnecessary. We
submit it to the profession with confidence as to their verdict.

As to our National Association, it will doubtless at its next meeting adopt
some measure to wipe out the stain which the act of its Vice-President has
inflicted on its honour.

I N D E X .

Adulterations of food and medicines, review

of Hassall and Marcet on, 394
Aguish disorder prevalent in London, 511
Air in veins, 541
Alcoholic fermentation, 207
Allaben, death from plugging pulmonary ar- j

tery, 558
Allen, death from chloroform, 273
Amaurosis from blow of whip, 265
with Bright's disease of the kid- ;

ney, 533

Amygdaline, transformation of, into hydro- j
cyanic acid, within the body, 282

Amylene, death from, 275, 544

employment of, 497

■ for children, 217 !

Amyloid degeneration of liver in yellow fe-
ver, 549

Anaemia, pvrophosphate of iron and soda in,
503

Anchylosed surfaces, rupture of, 246
Andre, tracheotomy in croup, 528
Andrews, mode of preserving vaccine virus,
561

Aneurism cured by displacing a portion of

its contents, 244
femoral, cured by manipulation,

290

Anselmier, turpentine in itch, 232
Antiperiodic, bittera febrifuga as, 502
Aorta, thoracic, complete obliteration of, 211
Apneumatosis, diagnosis of, 226
Articular cartilages, pathology of, 234
Assimilation of oleaginous substances, 496
Atrophy of voluntary muscles, 232
Ayres, dislocation of cervical vertebrae. 289
Azotized food, function of pancreas in digest-
ing, 206

Beale, Anatomy of tbe Liver, notice of. 491 j
Becquerel, electricity in suppression of lac-
teal secretion, 521
Bell, sympathetic inflammation of eye, 263
Belladonna plaster to skin, poisoning by, 278 j
Bennett, ovariotomy, 284, 357
Bernard, formation of sugar in the liver, 203 j
Berthe, assimilation of oleaginous substances.
496

Bertholet, alcoholic fermentation, 207
Betz. external use of clav. 217

Bile, constitution and physiology of, 305
Bismuth, preparation and therapeutic em-
ployment of subcarbonate of, 504
Bittera febrifuga as an antiperiodic, 502
Blackman, excision of head of humerus, 560

femoral aneurism. 290

TTutzer's operation for hernia.

292

Blair, Yellow Fever of British Guiana, notice
of, 481

Blepharospasmus relieved by chloroform, 535
Blondlot, mode of action of gastric juice, 207
Blot, saccharine urine in nursing women, 271
Bond, splint for dressing diseases and injuries

of elbow-joint, 344
Boudault, chemical and physiological proper-
ties of pepsin, 214
Bowditch, paracentesis thoracis, 291
Briquet, Therapeutical Treatise on Cinchona ,

review of, 142
Broadhurst, rupture of partial anchylosis, 246
Brown, chlorate of potash injections in leu-

corrhcea, 66
ovarian dropsy treated by iodine in-
jections, 261
Bryant, bony union after fracture of cervix
femoris, 252

pathology of articular cartilages, 234

Butler Hospital for Insane, notice of report
of, 464

California State Asylum for Insane, notice of

report of, 190
Campbell, claim to priority of discovery of

the excito-secretory system of nerves, 177
Cancer, constitutional origin and treatment

of, 240
necrosis of, 241

Cancerous and other tumours, hereditary

transmission of, 522
Cantharides, poisoning by, 559
Capillary circulation, phenomena of, 13
Carbonic oxide, anaesthetic action of, 499
Casselberry, water in treatment of fever, GS
Cataract, hemorrhage after extraction of, 535

ill results of depression for, 537

ought both eyes to be operated on

at the same time? 267

relation of, to heart disease, 266

Cervical vertebrae, dislocation of, 289. 557
Cervix femoris, bony union after fracture of,
252

564

INDEX.

Chalk and vinegar in intermittent fever, 291
Cheeks, redness of, as a symptom of pneu-
monia, 513

Chlorate of potash, injections of, in leucor-
rhoea, 66

in mercurial stomatitis,

Chloroform and ether, death from, 281

death from, 273

gelatinized, 505

poisoning by, 367

Cholera, new premonitory symptom of, 514
Churchill on Diseases of Women, notice of,
198

Clavicle, extirpation of, 350
Clay, external use of, 217

ovariotomy, 530

Cocoa-nut oil, therapeutic use of, 503
Colchiceine, 505

Colchicum autumnale, new principle of, 505

Cold water applied externally, effect of, on
circulation, 501

Collin, digestion and absorption of fatty sub-
stances without the concurrence of the pan-
creatic juice, 206

Collodion and corrosive sublimate as an es-
charotic, 506

Compound dislocation of the long bones, 324

Concretions of the prostate, 530

Connecticut, notice of Annual Convention of
Medical Society of, 443

Constipation, prevention of, 230

Consumption, glycerine in, 521

■ microscope in the diagnosis of,

514

Cooke, constitutional origin and treatment

of cancer, 240

manganese cum potassa, 505

Coolidge, Statistical Report of Sickness and

Mortality in the U. S. Army, review of,

119

Cooper, hemorrhage after extraction of cata-
ract, 535

Coote, amaurosis with Bright's disease of the
kidney, 533

use of ophthalmoscope, 261

Corrosive sublimate and collodion as an es-
char otic, 506

Corvisart, function of pancreas in digestion
of azotized food, 206

Cotton, glycerine in consumption, 521

Creasote in erysipelas, 232

Crockett, death from inhaling a mixture of
chloroform and ether, 284

Croup, tracheotomy in, 528

Curtis, extirpation of clavicle, 350

Cyclamen Europseum, 279

Dalton, constitution and physiology of the
bile, 305

Delafond, certain physiological phenomena
connected with parturition and lactation
in bitches, Ac, 496

Delarue, creasote in erysipelas, 232

Demarquay, therapeutic properties of iodide
of potassium, 217

Delioux, bittera febrifuga, 502

Delirium tremens following pneumonia, 559
Development, arrest of, 286
Diabetes, 229

■ concretion on nervus vagus, 508

etiology of, 506

Diphtheritic ophthalmia, 534
Douglas, Gelseminum sempervirens in gonor-
rhoea, 560

Dunglison, Materia Medica and Therapeu-
tics, notice of, 491
Dysentery and its treatment, 192
Dyspepsia, lactic acid as a cure for, 231

Earle, cases of partio-general paralysis, 36
Edwards, gonorrhoea of the nose, 531
Elbow-joint, splint for, 344
Electricity in suppression of lacteal secretion ,
521

Enucleation treatment of uterine fibrous tu-
mours, 529

Epilepsy, analysis of 52 cases of, 222

Erectile apparatus of eye, 496

Eruptive fevers, mortality from, at different
periods of the year, 510

Erysipelas, creasote in, 232

tobacco in, 292

Ether and chloroform gelatinized, 505

Excision of head of humerus, 560

Excito-secretory system of nerves, priority
of discovery of, 177

Eye, erectile apparatus of, 496

Fatty degeneration of voluntary muscles, 232

substances, digestion and absorption

of, without the concurrence of the pancre-
atic juice, 206
Femur, bony union after fracture of, 252
dislocation of, reduced by manipu-
lation, 292

excision of head of, 248, 525

fracture of, four times, at same place,

524

spontaneous fracture of, 524

Fergusson, excision of enlarged third lobe

of prostate in lithotomy, 257, 526
Ferruginous comfits, 217

wine of bark, 217

Fever, water in the treatment of, 68
Fibrin, its nature, &c, 495
Fibrinous plugs in aorta, &c, 286
Fischer, Catalogue of Library of Pennsyl-
vania Hospital, notice of, 458
Flint, phenomena of the capillary circula-
tion, 13

Follet and Baume, pyrophosphate of iron in
anaemia, 503

Foramen ovale, open, 517

Forbes, Nature and Art in the Cure of Dis-
ease, review of, 409

Fracture of neck of femur within the capsule,
bony union, 252

Friedberg, myopathic luxation, 253

Frontal sinus, fracture connecting with, &c,
553

Funis, statistics of coiling of, 540

INDEX.

565

Gabb, liquor sodae chlorinatae in smallpox,
232

Gallaher, chlorate of potash in mercurial

stomatitis, 64
Garrod, diabetes, 229
Gastric juice, mode of action of, 207
Gelseminum sempervirens in gonorrhoea, 560
Gibbon, identity of causes of typhus and ty-
phoid fever, 220
Gintrac, Pathology and Therapeutics, review
of, 420

Giraldes, employment of amylene for child-
ren, 217

on amylene, 499

Glucogenic hepatic matter, 203

Glucose, influence of alkalies and alkaline
carbonates in destroying, 205

Glycerine as a preservative of vaccine virus,
561

in consumption, 521

Goldsborough, herpes preputialis, 556
Gonorrhoea, gelseminum sempervirens in,
560

of the nose, 531

Grant, extrusion of foetus with membranes

entire, 554

gunshot wound, 292

Gubler, redness of cheeks as a symptom of

pneumonia, 513
Gunshot wound of heart and stomach, 292

Hall's ready method, successful employment
of, 347

Hamilton, compound dislocation of the long
bone?, 324

Hancock, excision of head of femur, 248

Hannon, preparation and therapeutic em-
ployment of subcarbonate of bismuth, 504

Harris's Keport of Marine Hospital, notice
of, 471

Hartford Retreat for Insane, notice of report
of, 466

Hassall and Marcet on Adulterations, &c.,

review of, 394
Head, cases of injury of, 51
Heart, gunshot wound of, 292

natural range of action of, 337

rupture of, 227

Hemorrhage after extraction of cataract, 535
Hernia, Wutzer's operation for, 292
Herniotomy in an infant, 261
Herpes preputialis, 556
Hewitt, diagnosis of apneumatosis, 224
Hirschfield, anatomy of supra-renal capsules,
493

Hodsden, chalk and vinegar in intermittent

fever, 291
Hooping-cough, treatment of, 517
Hughes, concussion of spinal cord, 237
Hutchinson, enucleation treatment of uterine

fibrous tumours, 529
rectangular staff for lithotomy,

531

stomatitis materna, 369

Hydrarthrosis of knee-joint, treatment of, 527

Illinois State Hospital for the Insane, notice
of, 187

Indiana State Hospital for Insane, notice of

report of, 186
Indian-corn in intermittent fever, 554
Indigenous Races of the Earth, notice of, 468
Insane asylum reports, notices of, 180, 461
Intermittent fever, chalk and vinegar in, 291

Indian-corn in, 554

Iodide of ammonium, 232

potassium, therapeutic properties

of, 217

Isaacs, Anatomy and Physiology of Kidney,

notice of, 492
Extent of Pleura above the Clavicle,

notice of, 492
Function of Malpighian Bodies of

Kidney, notice of, 492
Itch, turpentine in, 232

Jackson, starch as a product of the liver, &c,

549

Jeannel, influence of alkalies and alkaline
carbonates in destroying glucose, 205

Jenner, poisoning by belladonna plaster to
skin, 278

Jones and Dickson, effect of cold water on

circulation, 501
aguish disorder prevailing in London,

511

complete obliteration of thoracic aorta,

211

Jordan, relation of cataract to heart disease,
266

Kadlburger on amylene, 499
Kelly, poisoning by tincture of cantharides,
559

Kerr, arrest of development, 286

mental influence of mother on foetus

extended through two pregnancies, 285
Kidneys, movable, 517

King's County Lunatic Asylum, notice of

report of, 467
Kirkes, Manual of Physiology, notice of, 201
Knee-joint, resection in certain diseases of,

249

Kneeland, spina bifida, with malformation of

genitals, 292
Kblliker and Muller, transformation of amyg

daline into hydrocyanic acid within the

body, 282

Lactic acid as a cure for dyspepsia, 231
Lead in snuff, poisoning by, 406, 542
Lee, natural range of heart's action, 337

use of speculum, 539

Leggatt, fatty degeneration and atrophy of
voluntary muscles, 232

566

INDEX.

Lente, recovery from fracture of spine, 361
successful employment of M. Hall's

ready method, 347
Leucorrhoea, chlorate of potash injections in,

Lithotomy, rectangular staff for, 531

Little, subclavian aneurism cured by Fergus-
son's method, 244

Liver in yellow fever, 549

notice of Beale on Anatomy of, 491

starch as a product of, 549

Luca, a new poison, 279

Lumpe, pregnancy in a two-horned uterus,
273

Macdonnell, treatment of hydrarthrosis, 527

Macke, corrosive sublimate and collodion as
an escharotic, 506

Mackenzie, photophobia and blepharospas-
mus relieved by chloroform, 535

Maine State Hospital for the Insane, notice
of report of, 461

Mammae, woman with four, 561

Manganese cum potassa, 505

Marine Hospital at Quarantine, notice of re-
port of, 471

Maxson, dislocation of cervical vertebrae,
557

May, sudden death after parturition, 541
Mayer, sterility, 272

McDowell, smallpox and its varieties, 353
McElbright, dislocation of femur reduced by

manipulation, 292
McLean Asylum for Insane, notice of report

of, 463

Mental influence of mother on foetus, 285
Mercurial stomatitis, chlorate of potash in,
64

Meyer, poisoning by lead in snuff, 542
Microscope in the diagnosis of consumption,
514

Milton, unusual and obstinate form of swell-
ing, 235

Mind, alleged unsoundness in old age, 280
Missouri State Asylum for Insane, notice of

report of, 189
Moullin, necrosis and enucleation of cancer,

241

Mount Hope Institution for Insane, notice of

report of, 184
Movable kidneys, 517
Murphy on puerperal fever, 269
Myopathic luxation, 252

Negro, change of colour in, 557

New Jersey State Lunatic Asylum, notice of
report of, 180

New York, notice of Transactions of Medi-
cal Society of, 437

Norfolk, notice of Eeport of Jommittee on
Origin of Yellow Fever at, 475

North Carolina State Asylum for the Insane,
notice of report of, 184

Transactions of Medical So-
ciety of, 445

Nose, gonorrhoea of, 531

Nott and Grliddon, Indigenous Races of the
Earth, notice of, 468

Nyman, diabetes, concretion on nervus va-
gus, 508

Oberlin, new principle of colchicum autum-

nale, 505
Obesity, 560

Ogle, open foramen ovale in the adult, 517
O'Ferral, rupture of heart, 227
Old age, alleged unsoundness of mind in, 280
Ophthalmological congress, 282
Ophthalmoscope, use of, 261
Oppolzer, movable kidneys, 517
Otto, Manual of Detection of Poisons, notice
of, 201

Ovarian dropsy treated by iodine injections,
261

Ovariotomy, 284, 357, 530

Ovum, extrusion of, with membranes entire,

553

Ozanam, anaesthetic action of carbonic oxide,
499

Packard, case of secondary hemorrhage, 54

cases of injuries of the head, 51

delivery of a female, one of whose

lower limbs had been disarticulated at the

hip-joint 17 years before, 283
Paget, hereditary transmission of tendencies

to cancerous and other tumours, 522
Pancreas, function of, in digesting azotized

food, 206
Paracentesis thoracis, 291
Partio-general paralysis, cases of, 36
Pearce, treatment of hooping-cough, 517
Pelvis, fracture of, during pregnancy, 283
Pennsylvania Hospital for the Insane, notice

of report of, 181
notice of Catalogue of

Library of, 458
notice of Transactions of Medi-
cal Society of, 449
State Hospital for the Insane,

notice of report of, 183
Pepsin, action of, 212

chemical and physiological proper-
ties of, 214

Pettenkofer, therapeutic use of cocoa-nut oil,

503

Philadelphia Hospital, Blockley, 561 '
Phillips, Indian-corn in intermittent fever,
554

Phoebus, prevention of constipation, 230
Photophobia relieved by chloroform, 535
Phthisis, curable stage of, 224
Pierson, obstetrical statistics, 56
Placenta praevia, statistics of, 540
Pneumonia, bloodletting in, 520

redness of cheeks as a symptom

of, 513

Poisoning by tincture of cantharides, 559
Pollitzer, spanaemia, chlorosis, &c, as the
characteristic of the present age, 513

INDEX.

567

Poznanski, new premonitory symptom of cho-
lera, 514

Pregnancy, influence of, in developing tu-
bercles, 87

in a two-horned uterus, 273

iodine in vomiting of, 272

Price, resection in certain diseases of knee-
joint, 249

Prostate, concretions of, 530

excision of enlarged third lobe in

lithotomy, 257, 526

Puerperal fever, 269

Pulmonary artery, death from plugging of,
558

Pyrophosphate of iron and soda in angemia,
503

therapeutic employ-
ment of, 215

Quinia, physiological action of disulphate of,
503

Ranke, physiological action of disulphate of
quinia, 503

Rayner, herniotomy in an infant, 261

Rees, etiology of diabetes, 506

Richardson, iodide of ammonium, 232

Robert on amylene, 497

Robin and Verdeil, Anatomical and Physio-
logical Chemistry, review of, 158

Robiquet, therapeutic employment of pyro-
phosphate of iron, 214

Roser, valvular nature of strangulated her-
nia, 260

Rouget, erectile apparatus of eye, 496
Rusponi, ether and chloroform gelatinized,
505

Saccharine urine in nursing women, 271
Salt, new Crimean tourniquet, 531
Sawyer, vesico-vaginal fistula, 258
Scarlatina, treatment of, with diluted acetic
acid, 27

Schmitt, iodine in vomiting of pregnancy,
272

Schneck, treatment of scarlatina by diluted

acetic acid,- 27
Schwarz, statistics of placenta praevia, 540
Secondary hemorrhage 56 days after gunshot

wound, 54
Sieveking, action of pepsin, 212
analysis of 52 cases of epilepsy,

222

Sloan, ought both eyes, when cataractous,

be operated on at the same time, 267
Smallpox and its varieties, 353

liquor sodas chlorinatae in, 232

Smith, curable stage of phthisis, 224
fracture of humerus by muscular ac-
tion, 525

Madeleine, trial of, 545

poisoning from chloroform, 367

quantity of air inspired under differ-
ent influences, 208

Snow, death from, 275

death from amylene, 544

Snuff, poisoning by lead in, 406, 542
South Carolina State Asylum for Insane, no-
tice of, 185

Spanaemia, chlorosis, &c, as the predominant

characteristics of the present age, 513
Speculum, use of, 539

Spina bifida, with malformation of genitals,
292

Spinal cord, concussion of, 237
Spine, fracture of, recovery from, 361
Spontaneous fractures, 524, 525
Staff, rectangular, for lithotomy, 531
Starch as a product of the liver, 549
Statistics of obstetrical cases, 56
Stephenson, tobacco in erysipelas, 292
Sterility, 272

Stomatitis materna, causes, nature, &c, of,
369

Sudden death after parturition, 541
Sugar, diabetic, not the same as that pro-
duced by liver in health, 506

mechanism of formation of, in the

liver, 203

Summerville, delirium tremens following

pneumonia, 559
Supra-renal capsules, anatomy of, 493 .
Sutton, change of colour in a negro, 557
Swelling, unusual and obstinate, form of, 235
Symblepharon cured by Blandin's method,

538

Syme, new operation for impermeable ure-
thra, 255

ununited fracture remedied by ope-
ration, 252
Sympathetic inflammation of eyeball, 263
Syncope from plugging pulmonary artery,
558

Taylor, symblepharon cured by Blandin's

method, 538
Thigh-bone, excision of head of, 525
fracture of, for the fourth time,

at same place, 524
Thigh-bones, spontaneous fracture of both,

524

Tholozan, diseases of the army of the East
during winter of 1854-5, 217

Thompson, concretions of the prostate, 530

microscope in the diagnosis of

consumption, 514

Tiedemann on Dysentery and its Treatment,
notice of, 192

Tinkham, ovariotomy, 555

Tobacco in erysipelas, 292

Todd on Diseases of the Urinary Organs and
Dropsies, notice of, 197

Tonsils, excision of, 287

Tourniquet, new Crimean, 531

Tracheotomy in croup, 258

Transactions of State Medical Societies, no-
tices of, 437

Tripe, mortality from eruptive fevers at dif-
ferent periods of the year, 510

Tubercles, influence of pregnancy in deve-
loping, 87

568

INDEX.

Turpentine in itch, 232

Typhus and typhoid fever, identity of causes
of, 220

TJ.

Ununited fracture remedied by operation,
252

lire, excision of head of femur, 525
Urethra, impermeable, new operation for,
255

Urine, saccharine conditions of, 229
Uterine fibrous tumours, 529
Uterus, two-horned, 273

Vaccine virus as a cure for smallpox, 552

preservation of, 561

Valvular nature of strangulated hernia, 260

Velpeau on amylene, 499

Vermont Asylum for Insane,' notice of report

of, 462
Vesico-vaginal fistula, 258
reviews of treatment

of, 387

Voluntary muscles, fatty degeneration and

atrophy of, 232
Vomiting of pregnancy, 272

Wallis, fracture of frontal bone, exposure of
nerve, 553

"Warren, does pregnancy accelerate or retard
the development of tubercles in the lungs
of persons predisposed to this disease? 87

excision of tonsils, 287

Warlomont and Testelin, diphtheritic oph-
thalmia, 534

"Water in the treatment of fever, 68

Western Pennsylvania Hospital, notice of re-
port of, 184

Whitaker, fracture of pelvis during preg-
nancy, 283

Wiedemann, statistics of coiling of funis,

540

Wilbur, fibrinous plugs in abdominal aorta,

&c, 286

Williams, Principles of Medicine, notice of,
479

Wilson on Diseases of the Skin, review of,
427

Wunderlich, bloodletting in pneumonia, 520
Wutzer's operation for hernia, 292

Yellow fever at Marine Hospital, New York,
471

at Norfolk, 475

of British Guiana, notice of, 481

Zimmermann on the nature of fibrin and the
cause of its coagulation, 495

American Journal of Med. Sciences. 569

UNIVERSITY OF PENNSYLVANIA— MEDICAL DEPARTMENT.

NINETY-SECOND SESSION (1857-58).

The Lectures will commence on Monday, October 12, and continue until the middle
of March.

Robert Hare, M. D., Emeritus Professor of Chemistry.
William Gibson, M. D., Emeritus Professor of Surgery.

Samuel Jackson, M. D., Professor of Institutes of Medicine.

George B. Wood, M. D., Professor of Theory and Practice of Medicine.

T tt ,r -rv f Professor of Obstetrics and the Diseases of Women and
Hugh L. Hodge, M. D., | Children.

Joseph Carson, M. D., Professor of Materia Medica and Pharmacy.
Robert E. Rogers, .M. D., Professor of Chemistry.
Joseph Leidt, M. D., Professor of Anatomy.

Henry H. Smith, M. D., Professor of Surgery.

William Hunt, M. D., Demonstrator of Anatomy.

Clinical Instruction is given at the Pennsylvania Hospital, and at the Philadelphia
Hospital.

Clinical instruction is also given, throughout the Session, in the Medical Hall, by
the Professors.

The Dissecting Rooms, under the superintendence of the Professor of Anatomy and
the Demonstrator, are open after the middle of September.

Fees for the Lectures (each Professor $15) $105

Matriculation Fee (paid only once) ...... 5

Graduation Fee 30

R. E. ROGERS, M. D., Dean of the Medical Faculty,
University Building.

F. B. DICK, Janitor, University Building.

UNIVERSITY OF LOUISIANA— MEDICAL DEPARTMENT.

The Annual Course of Lectures in this department will commence on Monday, No-
vember 16, 1857, and will terminate in the ensuing March.

James Jones, M. D., Professor of Practice of Medicine.

J. L. Riddell, M. D., Professor of Chemistry.

Warren Stone, M. D., Professor of Surgery.

A. H. Cenas, M.D., Professor of Obstetrics.

Gustavus A. Nott, M. D., Professor of Materia Medica.
Josiah C. Nott, M. D., Professor of Anatomy.

Thomas Hunt, M. D., Professor of Physiology and Pathology.

Gilbert S. Vance, M. D., Demonstrator of Anatomy.
The rooms for Dissecting will be open on the second Monday in October.
The Faculty are Visiting Physicians and Surgeons of the Charity Hospital.
The Students accompany the Professors in their visits, and, free of expense, enjoy
extraordinary practical advantages.

Preliminary to the Course, Lectures will be delivered daily in the amphitheatre of
the Hospital, from the 1st of October, on Clinical Medicine and Surgery, and other
subjects, without any charge to students.

THOMAS HUNT, M.D., Dean.
The Administrators of the Charity Hospital elect annually, in April, fourteen Resi-
dent Students, who are maintained by the Institution.

570

American Journal of Med. Sciences.

JEFFERSON MEDICAL COLLEGE.

The Course of Lectures will commence on Monday, the 12th of October, and con-
tinue until the 1st of March.

Thos. D. Mutter, M. D., Emeritus Professor of Surgery.

Robert M. Huston, M. D., { E™ftus Professor of Materia Medica and General
' ' \ Therapeutics.

Institutes of Medicine, etc., . . . .By Prof. Robley Dunglison, M. D.

General, Descriptive and Surgical Anatomy,
Practice of Medicine, .
Obstetrics and Diseases of Women and Children,
Chemistry, .......

Institutes and Practice of Surgery,
Materia Medica and General Therapeutics,

Joseph Pancoast, M. D.
J. K. Mitchell, M. D.
Charles D. Meigs, M. D.
Franklin Bache, M.D.
Samuel D. Gross, M. D.
Thomas D. Mitchell, M.D.

Demonstrator of Anatomy, . . Ellerslie Wallace, M. D.

Clinics will be held regularly during the month of September ; and every Wednes-
day and Saturday in the month of October, and during the course, Medical and
Surgical cases will be investigated, prescribed for, and lectured on before the Class.
During the year ending March the first, 1857, about sixteen hundred cases were
treated, and about two hundred operations were performed ; amongst them many
major operations — as amputation of the thigh and leg, extirpation of the upper jaw,
mammse, &c, lithotomy, trephining, resection of the elbow-joint, and ligation of
the external iliac artery.

The lectures are so arranged as to permit the student to attend the medical and
surgical practice and lectures at the Pennsylvania Hospital.

On and after the 1st of October, the dissecting rooms will be open, under the direc-
tion of the Professor of Anatomy and the Demonstrator.

Fees :

Matriculation, which is paid only once, $ 5

To each Member of the Faculty $15, 105

Graduation, 30

ROBLEY DUNGLISON, M.D.,

Dean of the Faculty.

KENTUCKY SCHOOL OF MEDICINE,

LOUISVILLE, KT.

The regular Session of this Institution commences on the first Monday in November,
and continues till the 1st of March. The usual preliminary course will be given in
October, at the College and Hospital.

FACULTY.

Emeritus Professor of Anatomy and Surgery.
Professor of Theory and Practice of Medicine.
Professor of Obstetrics and Clinical Medicine.
Professor of Medical Chemistry.
, Professor of the Principles and Practice of Surgery.
Professor of Materia Medica and Therapeutics.
Professor of Special Anatomy.

Professor of Physiology and Pathological Anatomy.
Demonstrator of Anatomy.
$105. Matriculation Fee, $5. Graduation Fee, $25.
Dissecting Ticket, $10.

Regular Clinical Lectures on Medicine and Surgery at the Hospital twice weekly
during the session. Clinical Lectures at the College every Saturday afternoon.

For further information, address N. B. MARSHALL, Dean,

Louisville, Ky., July 10, 1857. College Buildings, cor. Green and Fifth Sts.

B. W. Dudley, M. D ,
Henry M. Bullitt, M. D.,
John Hardin, M. D.,
Charles W. Wright, M. D.,
Middleton Goldsmith, M. D,
N. B. Marshall, M. D.,
W. D. Sterman, M. D.,
Geo. W. Bayless, M. D.,
D. Cummings, M. D.,

Fees for the entire course,

American Journal of Med. Sciences.

571

PENNSYLVANIA COLLEGE— MEDICAL DEPARTMENT.

SESSION OF 1857-58.

The regular Course of Lectures will commence on Monday, October 12th, and will
be continued until the 1st of March.

FACULTY.

David Gilbert, M. D., Professor of Obstetrics and Diseases of Women and Children.

Alfred Stille\ M. D., Professor of Theory and Practice of Medicine.

John Neill, M. D., Professor of Surgery.

John J. Reese, M. D., Professor of Medical Chemistry.

John B. Biddle, M. D., Professor of Therapeutics and Materia Medica.

Francis G. Smith, M. D., Professor of Institutes of Medicine.

T. G. Richardson, M. D., Professor of General and Special Anatomy.

H. W. De Saussure Ford, M. D., 1 . ' . ,

J. Frank Bell, M. D., } demonstrators of Anatomy.

FEES.

For the "entire Course of Lectures .... $105 00

Matriculation (paid once only) 5 00

Graduation 30 00

The Dissecting Rooms will be opened in September, under the direction of the Pro-
fessor of Anatomy.

Preliminary Lectures will be delivered during the fortnight preceding the opening
of the session.

FRANCIS G. SMITH, M. D., Registrar,
July, 1857. No. 1501 Walnut Street, Philadelphia.

OGLETHORPE MEDICAL COLLEGE,

SAVANNAH, GEORGIA.

The regular course of Lectures in this Institution will commence on Monday,
November 2, and continue four months. A preliminary course will commence on the
20th October.

The requirements for graduation are similar to those of other Medical Colleges in
the United States.

Students will have ample clinical instruction, and surgical operations are always
performed before the class when practicable.

A very liberal Beneficiary foundation is established in the College.
Good board may be had at from $3 50 to $5 00 per week.

FACULTY.

Professor of Obstetrics and Diseases of Women and

Children.
Professor of Anatomy.

Professor of Chemistry and Pharmacy.
Demonstrator of Anatomy.

Holmes Steele, M. D., Dean,

J. S. Morel, M. D.,
H. L. Btrd, M. D.,
J. W. Benson, M. D.,
J. R. Smith, M. D.,
Ira E. Dupree, M. D.,

Jules Le Hardy, M. D.,
Hugh A. Blair, M. D.,

FEES.

For the full course .

Demonstrator

Matriculation

City Hospital (optional)

Diploma

$105 00
10 00
5 00
5 00
30 00

572

American Journal of Med. Sciences.

PHILADELPHIA COLLEGE OF MEDICINE.

Fifth Street, below "Walnut.
SESSION 1857-8.
FACULTY.

Alfred T. King, M.D., Emeritus Professor of Practice of Medicine.

B. Howard Rand, M. D., Professor of Medical Chemistry.

Henry Hartshorne, M. D., " Practice of Medicine.

Lewis D. Harlow, M. D., " Obstetrics, &c.

William S. Halset, M. D., " Surgery.

Wm. Hembel Taggart M. D., " Materia Medica.

James Aitken Meigs, M. D., " Institutes of Medicine.

W. H. Gobrecht, M. D., " Anatomy.

William Bradley, M. D., Demonstrator of Anatomy.

Fees : Matriculation, $5; one Full Course, $100; Perpetual Ticket, $150; Gradua-
tion, $30; Practical Anatomy, $10; Material for Dissection, free. Second course
Students are furnished with the Hospital Ticket without charge. Lectures will com-
mence early in October, and terminate in March. Hereafter this College will have
but one Commencement annually ; the Summer Lectures being made supplementary,
only, to the Winter Course.

For further information, address B. HOWARD RAND, M.D., Dean.

MEDICAL COLLEGE OF VIRGINIA.

SESSION OF 1857-' 58.

The regular Course of Lectures will commence on the 1st of October, and continue until the 1st of
March.

Charles Bell Gibson, M. D., Professor of Surgery and Surgical Anatomy.
David H. Tucker, M. D., Professor of Theory and Practice of Medicine.

Martin P. Scott, M. D., Professor of Chemistry and Pharmacy.

Beverley E. Wellford, M.D., Professor of Materia Medica and Therapeutics.
Arthur E. Peticolas, M. D., Professor of Anatomy.

Levin S. Jotnes, M. D., Professor of Institutes of Medicine and Medical Jurisprudence.

James H. Conway, M. D. Professor of Obstetrics and Diseases of Women and Children.

Marion Howard, M. D., Demonstrator of Anatomy.

The study of Practical Anatomy may be prosecuted with the most ample facilities, and at a very
trifling expense.

FEES.

For the entire Cour&e of Lectures $105

Practical Anatomy 10

Matriculation Fee- 5

Graduation Fee 25

L. S. JOTNES, M. D.,

April, 1857. Bean of the Faculty.

American Journal of Med. Sciences.

573

FISKE MEDICAL PRIZE QUESTION.

THE TRUSTEES OF THE FISKE FUND,

ANNUAL MEETING OF THE RHODE ISLAND MEDICAL SOCIETY,
Held at Providence, June 3, 1857, announced that the premium of One
Hundred Dollars offered by them in 1857, for the best dissertation on the
following subject : —

"WHAT ARE THE CAUSES AND NATURE OF THAT DISEASE
INCIDENT TO PREGNANCY AND LACTATION, CHARACTER.
IZED BY INFLAMMATION AND ULCERATION OF THE MOUTH
AND FAUCES, USUALLY ACCOMPANIED BY ANOREXIA, EMA-
CIATION AND DIARRHGEA, AND WHAT IS THE BEST MODE
OF TREATMENT ?" has been awarded to the author of the dissertation

bearing this motto —

" Wheat from the fields of science, and cockles from my own farm."

And upon breaking the seal of the accompanying packet, they learned that
the successful competitor was David Hutchinson, M. D.; of Mooresville,
Morgan County, Indiana.

They propose the following subjects for 1858 : —

I. THE EFFECTS OF THE USE OF ALCOHOLIC LIQUORS ON
TUBERCULAR DISEASE, OR IN CONSTITUTIONS PREDISPOSED
TO SUCH DISEASE.

To be supported by facts presented as far as possible in a statistical form.

II. THE MORBID EFFECTS OF RETENTION IN THE BLOOD
OF THE ELEMENTS OF THE URINARY SECRETIONS.

For the best dissertation on each of these subjects the Trustees will pay
One Hundred Dollars.

Every competitor for a premium is expected to conform to the following
regulations, viz : —

To forward to the Secretary of the Trustees, on or before the first day of
May, 1858, free of all expense, a copy of his dissertation, with a motto writ-
ten thereupon, and also accompanying a sealed packet, having the same motto
inscribed upon the outside, and his name and place of residence within.

Previously to receiving the premium awarded, the author of the successful
dissertation must transfer to the Trustees all his right, title and interest in
and to the same, for the use, benefit and behoof of the Fiske Fund.

Letters accompanying the unsuccessful dissertations will be destroyed by
the Trustees, unopened, and the dissertations may be procured by their re-
spective authors, if application be made therefor within three months.

AT THE

S. Aug. Arnold, M. D.7 Providence, Secretary.

574

American Journal of Med. Sciences.

BOYLSTON MEDICAL PRIZE QUESTIONS.

The Boylston Medical Committee, appointed by the President and Fellows of Har-
vard University, consists of the following Physicians : —

Edward Reynolds, M. D. J. M. Warren, M. D.

John Jeffries, M. D. D. H. Storer, M. D.

S. D. Townsend, M. D. Charles Gt. Putnam, M. D.

J. B. S. Jackson, M. D. Morrill Wyman, M. D.

Henry J. Bigelow, M. D.

At the Annual Meeting of the Committee, on Wednesday, August 5, 1857, a premium
of Sixty Dollars, or a gold medal of that value, was awarded to Wm. W. Morland,
M. D., of Boston, for a dissertation on the following question: —

" The Pathology and Treatment of the Diseases of the Urinary Organs."

The other Boylston Premium of the same value, was awarded to Ephraim Cutter,
M. D., of Woburn, for a dissertation on

" Under what circumstances do the usual Signs furnished by Auscultation and Percus-
sion prove fallacious ?"

The questions for 1858 are: —

1. Spermatorrhoea — its Causes, Consequences, and Treatment.

2. Human Parasites, Animal and Vegetable, their Anatomy, Development, Natural
History, and Treatment.

Dissertations on these subjects must be transmitted, post paid, to Edward Rey-
nolds, M. D., on or before the first Wednesday of April, 1858.
The following questions are proposed for 1859 : —

1. Hew and useful views upon any subject in Medicine or Surgery.

2. Tubercle — its Pathology, and especially its Relation to Inflammation.
Dissertations on these subjects must be transmitted as above, on or before the first

Wednesday of April, 1859.

The author of the best dissertation considered worthy of a premium, on either of
the subjects presented for 1858, will be entitled to a premium of one hundred and
twenty dollars, or a gold medal of that value, at his option.

The author of the best dissertation considered worthy of a premium on either of
the subjects presented for 1859, will be entitled to a premium of sixty dollars, or a
gold medal of that value, at his option.

Each dissertation must be accompanied by a sealed packet, on which shall be written
some device or sentence, and within shall be inclosed the author's name and residence.
The same device or sentence is to be written on the dissertation to which the packet
is attached.

The writer of each dissertation is expected to transmit his communication to the
Chairman of the Committee, in a legible handwriting, within the time specified.

All unsuccessful dissertations are deposited with the Secretary, from whom they
may be obtained, with the sealed packet unopened, if called for within one year after
they have been received.

By an order adopted in 1826, the Secretary was directed to publish annually the
following votes : —

1st. That the Board do not consider themselves as approving the doctrines con-
tained in any of the dissertations to which premiums may be adjudged.

2d. That in case of publication of a successful dissertation, the author be considered
as bound to print the above vote in connection therewith.

D. HUMPHREYS STORER,

Boston, Aug. 7, 1857. Secretary.

American Journal of Med. Sciences.

575

TRANSYLVANIA UNIVERSITY— MEDICAL DEPARTMENT.

The Forty-First Session will commence on the First Monday in November, 1857,
and will continue four months, under the direction of the following Faculty, viz : —
Benjamin W. Dudley, M. D., Emeritus Professor of Surgery.
Robert Peter, M. D., Professor of Chemistry and Pharmacy.

James M. Bush, M. D., Professor of Anatomy.

William S. Chiplet, M. D., Professor of Theory and Practice of Medicine.
Ethelbert L. Dudley, M.D., Professor of Principles and Practice of Surgery.
Samuel M. Letcher, M. D., Professor of Obstetrics and Diseases of Women and

Children.

Henry M. Skillman, M. D., Professor of General and Pathological Anatomy and

Physiology.

Benjamin P. Drake, M. D., Professor of Materia Medica, Medical Jurisprudence

and Therapeutics.
James M. Bruce, M. D., Demonstrator of Anatomy.

Tickets to the full course $105. Matriculation and Library Fee, $5. Gra-
duation Fee, $25. Demonstrator's Ticket, $10. All in advance.
Good Boarding, with fuel and lights, from $3 00 to $4 00 per week.

ROBERT PETER, M. D.,
Lexington, Ky., July 14, 1857. Dean, -§c.

UNIVERSITY OF NASHVILLE— MEDICAL DEPARTMENT.
SESSION OF 1857-58.

The Seventh Annual Course of Lectures in this Institution will commence on Monday,

the 2d of November next, and continue till the first of the ensuing March.

Thomas R. Jennings, M. D., Professor of Anatomy.

J. Berrien Lindsley, M. D., Professor of Chemistry and Pharmacy.

C. K. Winston, M. D., Professor of Materia Medica and Med. Jurisprudence.

A. H. Buchanan, M. D., Professor of Surgical Anatomy and Physiology.

t~ at nr „ tit -rv f Professor of Obstetrics and the Diseases of Women and

John M. Watson, M. D., j children.

Paul F. Eve, M. D., Professor of Principles and Practice of Surgery.

W. K. Bowling, M. D., Professor of Institutes and Practice of Medicine.

William T. Briggs, M. D., Adjunct Professor and Demonstrator of Anatomy.

The Anatomical Rooms will be opened for students on the first Monday in October
(the 5th).

A Preliminary Course of Lectures, free to all students, will be given by the Profes-
sors, commencing also on the first Monday of October.

The Tennessee State Hospital, under the direction of the Faculty, is open to the
Class free of charge.

A Clinique has been established in connection with the University, at which opera-
tions are performed, and cases prescribed for, and lectured upon, in the presence of
the class.

Amount of Fees for Lectures is $105. Matriculation Fee (paid once only), $5.
Practical Anatomy, $10. Graduation Fee, $25.

Good Boarding can be procured for $3 to $4 per week. For further information,
or Catalogue, apply to PAUL F. EVE, M. D.,

Nashville, Tenn , July 16, 1857. Dean of the Faculty.

576

American Journal of Med. Sciences.

MEDICAL COLLEGE OF GEORGIA,

AT AUGUSTA.

The Twenty-Sixth Course of Lectures in this Institution, will commence on Monday,
the 2d November next.

G. M. Newton, M. D., Emeritus Professor of Anatomy.

H. F. Campbell, M. D., Anatomy.
L. A. Dugas, M. D., Surgery.

L. D. Ford, M. D., Institutes and Practice of Medicine.

I. P. Garvin, M. D., Materia Medica, Therapeutics and Medical Jurisprudence.
J. A. Eve, M. D., Obstetrics and Diseases of Women and Infants.

H. V. M. Miller, M. D., Physiology and Pathological Anatomy.

Alex. Means, M. D., Chemistry and Pharmacy.

Rgbt. Campbell, M. D., Demonstrator of Anatomy.

S. B. Simmons, M. D., Assistant Demonstrator of Anatomy.

Clinical Lectures will be delivered in the City Hospital and at the Jackson Street
Hospital.

Fee for whole Course, $105.

Matriculation Ticket (to be taken once), $5.

For further particulars, apply to any member of the Faculty, or to

I. P. GARVIN, Dean.

MEMPHIS MEDICAL COLLEGE.

The Regular Lectures of this College will commence on Monday, the 2d of Novem-
ber, and will continue four months.

FACULTY.

John Millington, M. D., Professor of Chemistry and Toxicology.

Ayres P. Merrill, M. D., Professor of Principles and Practice of Medicine.

t o Tv/r -n f Professor of Obstetrics and Diseases of Women and

Lewis Shanks, M. D., | children.

Arthur K. Taylor, M. D., Professor of Anatomy.
Howel R. Robards, M. D., Professor of Surgery.

C. B Guthrie, M. D., Professor of Materia Medica and Pharmacy.
Daniel F. Wright, M. D., Professor of Physiology and Pathology.

George F. Jones, M. D., Demonstrator of Anatomy.
J. F. Marable, M. D., Curator of the Museum.

L. SHANKS, M. D., Dean of the Faculty.

The Fee, for the entire Course, is $105, payable in advance. Matriculation Fee,
$5 ; Graduating Fee, $25 ; Anatomy and Dissection, $10. This Ticket must be
taken once before graduating. The Dissecting Rooms open from the 1st of October.

A Preliminary Course of Lectures, free to all students, will be given by each Pro-
fessor, commencing on Monday the 12th of October, and will be continued until the
commencement of the regular course.

CLINICAL INSTRUCTION.
The Memphis Charity Hospital is open for the visits of students, and will be visited
regularly by one of the Faculty. The College Dispensary is open every morning ;
when about 1,000 patients are exhibited and prescribed for before the class.

The College contains an ample Museum, a Chemical and Philosophical Apparatus,
and everything necessary to demonstrate the Course of Lectures on all the branches.

Students desiring further information will address Professor L. Shanks, or call on
him at his office on Main Street.

L. SHANKS, M. D., Dean.

Date Due

SMITHSONIAN INSTfTUTION LIBRARIES

3 9088 01224 9553

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